1689656720 NPI number — EDWARD A DIPRETA MD

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689656720 NPI number — EDWARD A DIPRETA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DIPRETA
Provider First Name:
EDWARD
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1689656720
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/13/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3008 E PARK AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BRUNSWICK
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31520-4241
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
912-265-2142
Provider Business Mailing Address Fax Number:
912-265-0530

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3008 E PARK AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRUNSWICK
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31520-4241
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
912-265-2142
Provider Business Practice Location Address Fax Number:
912-265-0530
Provider Enumeration Date:
11/15/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X , with the licence number:  052707 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207NI0002X , with the licence number: 052707 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207NS0135X , with the licence number: 052707 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207ND0900X , with the licence number: 052707 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207ND0101X , with the licence number: 052707 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207NP0225X , with the licence number: 052707 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 487177354 , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: DC4061 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: P00182483 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 52046337014 . This is a "BCBS (BWKDERM)" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 52046337012 . This is a "BCBS (GA DERM)" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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