Provider Demographics
NPI:1447458831
Name:DERUITER, MARK (PHD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:DERUITER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:164 PILLSBURY DR SE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55455-0279
Mailing Address - Country:US
Mailing Address - Phone:612-624-5755
Mailing Address - Fax:612-624-7586
Practice Address - Street 1:164 PILLSBURY DR SE
Practice Address - Street 2:115 SHEVLIN HALL
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55455-0279
Practice Address - Country:US
Practice Address - Phone:612-624-5755
Practice Address - Fax:612-624-7586
Is Sole Proprietor?:No
Enumeration Date:2007-07-06
Last Update Date:2007-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5987231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist