Basic Information
| Provider Information | |||||||||
| NPI: | 1720241094 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GAITAN RUEDA | ||||||||
| FirstName: | JUAN | ||||||||
| MiddleName: | ISRAEL | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1255 HIGHWAY 54 W | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302144526 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4043673014 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1255 HIGHWAY 54 W | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302144526 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4043673014 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2008 | ||||||||
| LastUpdateDate: | 01/02/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0200X | 076716 | GA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | 207RP1001X | 076716 | GA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
No ID Information.