Provider Demographics
NPI:1730110651
Name:DEBERRY-CARLISLE, ADAIR (DO)
Entity Type:Individual
Prefix:DR
First Name:ADAIR
Middle Name:
Last Name:DEBERRY-CARLISLE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:988102 NEBRASKA MEDICAL CENTER
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68198-8102
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:630 S FLEISHEL AVE
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-2041
Practice Address - Country:US
Practice Address - Phone:903-606-5560
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-06
Last Update Date:2023-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM0050208600000X
NE1974208600000X, 2086S0127X
OK68362086S0127X
AZ0079212086S0127X
WI71035-212086S0127X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8AN626OtherBCBSTX
TX197530202Medicaid
OK200908280AMedicaid
TXP02531927OtherMEDICARE RAIL ROAD