MEDICARE: DR. DAVID T DERRER M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	054181	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	054181	OTHER	GA	GEORGIA MEDICAL LICENSE #
2	015928	OTHER	GA	BLUE CROSS/BLUE SHIELD #

General Provider Information

NPI Number	:	1659378412
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DAVID T DERRER M.D.

Provider Business Mailing Address
First Line	:	805 SANDY PLAINS ROAD
Second Line	:	MEDICAL STAFF SERVICES
City	:	MARIETTA
State	:	GA
Zip	:	30066-6340
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4550 COBB PARKWAY NORTH NW STE 101
Second Line	:
City	:	ACWORTH
State	:	GA
Zip	:	30101
Country	:	US
Telephone Number	:	470-956-0100
Fax Number	:	770-529-0279

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/07/2005
Last Update Date	:	03/07/2023

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