Provider Demographics
NPI:1063860617
Name:DEBERMUDEZ, VIRGINIA LEON (MD)
Entity Type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:LEON
Last Name:DEBERMUDEZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:VIVI
Other - Middle Name:
Other - Last Name:LEON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:403 WALKAWAY CT
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37043-6741
Mailing Address - Country:US
Mailing Address - Phone:931-450-8484
Mailing Address - Fax:
Practice Address - Street 1:403 WALKAWAY CT
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37043-6741
Practice Address - Country:US
Practice Address - Phone:931-450-8484
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-24
Last Update Date:2016-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ZZ178.361207Q00000X, 208D00000X
175F00000X, 174H00000X, 175F00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No175F00000XOther Service ProvidersNaturopath
No174H00000XOther Service ProvidersHealth Educator
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant