Healthcare Provider Details

I. General information

NPI: 1689656720
Provider Name (Legal Business Name): EDWARD A DIPRETA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/15/2005
Last Update Date: 02/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3008 E PARK AVE
BRUNSWICK GA
31520-4241
US

IV. Provider business mailing address

3008 E PARK AVE
BRUNSWICK GA
31520-4241
US

V. Phone/Fax

Practice location:
  • Phone: 912-265-2142
  • Fax: 912-265-0530
Mailing address:
  • Phone: 912-265-2142
  • Fax: 912-265-0530

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number052707
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207NI0002X
TaxonomyClinical & Laboratory Dermatological Immunology Physician
License Number052707
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number052707
License Number StateGA
# 4
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number052707
License Number StateGA
# 5
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number052707
License Number StateGA
# 6
Primary TaxonomyN
Taxonomy Code207NP0225X
TaxonomyPediatric Dermatology Physician
License Number052707
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: