Healthcare Provider Details

I. General information

NPI: 1043507213
Provider Name (Legal Business Name): CAITLYN MAE RERUCHA MD, MSED, FAAFP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MS. CAITLYN MAE FALLER

II. Dates (important events)

Enumeration Date: 07/07/2011
Last Update Date: 05/28/2024
Certification Date: 05/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

36065 SANTA FE AVE
FORT CAVAZOS TX
76544-5060
US

IV. Provider business mailing address

36065 SANTA FE AVE
FORT CAVAZOS TX
76544-5060
US

V. Phone/Fax

Practice location:
  • Phone: 254-288-8280
  • Fax:
Mailing address:
  • Phone: 254-288-8280
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number0101253730
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: