Provider Demographics
NPI:1912992587
Name:DAVID W RETTERBUSH MD PC
Entity type:Organization
Organization Name:DAVID W RETTERBUSH MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:RETTERBUSH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:229-244-0034
Mailing Address - Street 1:PO BOX 3638
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31604-3638
Mailing Address - Country:US
Mailing Address - Phone:229-244-0034
Mailing Address - Fax:229-244-1871
Practice Address - Street 1:403 COWART AVE
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-2635
Practice Address - Country:US
Practice Address - Phone:229-244-0034
Practice Address - Fax:229-244-1871
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-20
Last Update Date:2008-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL51883208600000X
KY19642208600000X
GA20145208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA525023OtherBS OF GA
GA511G700378OtherGROUP PROVIDER TRANSACTION ACCESS NUMBER ( PTAN)
GA000193278AMedicaid
GA020022209OtherRAILROAD MEDICARE
C78455Medicare UPIN