=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093777658
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SCOTT ALAN DERUITER M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/06/2006
-----------------------------------------------------
Last Update Date | 03/28/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 109 S BURLINGTON DR
-----------------------------------------------------
City | PUEBLO
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81007-5560
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-553-2205
-----------------------------------------------------
Fax | 833-314-0183
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 9000
-----------------------------------------------------
City | PUEBLO
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81008-9000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-553-2200
-----------------------------------------------------
Fax | 719-553-2216
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 43016
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------