Provider Demographics
NPI:1972581452
Name:CARRUTH, JOSEPH E (MD)
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:E
Last Name:CARRUTH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 407
Mailing Address - Street 2:
Mailing Address - City:VIDALIA
Mailing Address - State:GA
Mailing Address - Zip Code:30475-0407
Mailing Address - Country:US
Mailing Address - Phone:478-275-3166
Mailing Address - Fax:478-277-1922
Practice Address - Street 1:104 FAIRVIEW PARK DR
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:GA
Practice Address - Zip Code:31021
Practice Address - Country:US
Practice Address - Phone:478-272-1366
Practice Address - Fax:478-277-1922
Is Sole Proprietor?:No
Enumeration Date:2006-01-05
Last Update Date:2015-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA019653207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000193355GMedicaid
GA000193355GMedicaid
GA202I060857Medicare PIN
GA1903199OtherFIRST HEALTH
GA000193355EMedicaid
GA7757271OtherAETNA
GA$$$$$$$$$AMedicare PIN