Provider Demographics
NPI:1457440992
Name:DEREBERY, MARY JENNIFER
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:JENNIFER
Last Name:DEREBERY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 W 3RD ST
Mailing Address - Street 2:SUITE 111
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90057-1944
Mailing Address - Country:US
Mailing Address - Phone:213-483-9930
Mailing Address - Fax:213-483-0905
Practice Address - Street 1:2100 W 3RD ST
Practice Address - Street 2:SUITE 111
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90057-1944
Practice Address - Country:US
Practice Address - Phone:213-483-9930
Practice Address - Fax:213-483-0905
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2013-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC42073207YX0602X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YX0602XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngic Allergy
Provider Identifiers
StateIdentifier IDID TypeIssuer
A89133Medicare UPIN
CAC42073Medicare PIN
CAWC42073BMedicare PIN