Provider Demographics
NPI:1639298482
Name:DEREBERY, VIRGINIA JANE (MD)
Entity Type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:JANE
Last Name:DEREBERY
Suffix:
Gender:F
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 27908
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78755-7908
Mailing Address - Country:US
Mailing Address - Phone:210-860-9146
Mailing Address - Fax:
Practice Address - Street 1:1345 PHILOMENA ST
Practice Address - Street 2:SUITE 102
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78723-3185
Practice Address - Country:US
Practice Address - Phone:512-324-5650
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-29
Last Update Date:2009-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG99522083X0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine