Provider Demographics
NPI:1679536163
Name:HUTTENBACH, DIRK E (MD)
Entity type:Individual
Prefix:
First Name:DIRK
Middle Name:E
Last Name:HUTTENBACH
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 1:4015 S COBB DR SE
Mailing Address - Street 2:SUITE 210
Mailing Address - City:SMYRNA
Mailing Address - State:GA
Mailing Address - Zip Code:30080-6303
Mailing Address - Country:US
Mailing Address - Phone:770-434-2436
Mailing Address - Fax:770-434-1223
Practice Address - Street 1:4015 S COBB DR SE
Practice Address - Street 2:SUITE 210
Practice Address - City:SMYRNA
Practice Address - State:GA
Practice Address - Zip Code:30080-6303
Practice Address - Country:US
Practice Address - Phone:770-434-2436
Practice Address - Fax:770-434-1223
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0139032084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Not Answered2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00089284AMedicaid
D29823Medicare UPIN