Provider Demographics
NPI:1750506838
Name:DERRYBERRY, BROC S (DC)
Entity Type:Individual
Prefix:MR
First Name:BROC
Middle Name:S
Last Name:DERRYBERRY
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5700 SE 74TH ST.
Mailing Address - Street 2:STE 300
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73135
Mailing Address - Country:US
Mailing Address - Phone:405-701-5777
Mailing Address - Fax:405-701-5778
Practice Address - Street 1:5700 SE 74TH ST
Practice Address - Street 2:STE 300
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73135
Practice Address - Country:US
Practice Address - Phone:405-701-5777
Practice Address - Fax:405-701-5778
Is Sole Proprietor?:No
Enumeration Date:2007-04-16
Last Update Date:2016-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3816111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor