Healthcare Provider Details

I. General information

NPI: 1093777658
Provider Name (Legal Business Name): SCOTT ALAN DERUITER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2006
Last Update Date: 03/28/2024
Certification Date: 03/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 S BURLINGTON DR
PUEBLO CO
81007-5560
US

IV. Provider business mailing address

PO BOX 9000
PUEBLO CO
81008-9000
US

V. Phone/Fax

Practice location:
  • Phone: 719-553-2205
  • Fax: 833-314-0183
Mailing address:
  • Phone: 719-553-2200
  • Fax: 719-553-2216

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number43016
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: