Provider Demographics
NPI:1043507213
Name:RERUCHA, CAITLYN MAE (MD, MSED, FAAFP)
Entity type:Individual
Prefix:DR
First Name:CAITLYN
Middle Name:MAE
Last Name:RERUCHA
Suffix:
Gender:F
Credentials:MD, MSED, FAAFP
Other - Prefix:MS
Other - First Name:CAITLYN
Other - Middle Name:MAE
Other - Last Name:FALLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:36065 SANTA FE AVE
Mailing Address - Street 2:
Mailing Address - City:FORT CAVAZOS
Mailing Address - State:TX
Mailing Address - Zip Code:76544-5060
Mailing Address - Country:US
Mailing Address - Phone:254-288-8280
Mailing Address - Fax:
Practice Address - Street 1:36065 SANTA FE AVE
Practice Address - Street 2:
Practice Address - City:FORT CAVAZOS
Practice Address - State:TX
Practice Address - Zip Code:76544-5060
Practice Address - Country:US
Practice Address - Phone:254-288-8280
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-07
Last Update Date:2024-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101253730207QS0010X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program