Provider Demographics
NPI:1578706263
Name:DERBORT, JASON DAVID (MD)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:DAVID
Last Name:DERBORT
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 1:14634 DOE RUN
Mailing Address - Street 2:
Mailing Address - City:HARVEST
Mailing Address - State:AL
Mailing Address - Zip Code:35749-7577
Mailing Address - Country:US
Mailing Address - Phone:662-242-7812
Mailing Address - Fax:
Practice Address - Street 1:14634 DOE RUN
Practice Address - Street 2:
Practice Address - City:HARVEST
Practice Address - State:AL
Practice Address - Zip Code:35749-7577
Practice Address - Country:US
Practice Address - Phone:662-242-7812
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-12
Last Update Date:2012-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALMD.31694207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine