Provider Demographics
NPI:1265941876
Name:DERNER, BRIAN
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:DERNER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6455 LAKE MEADOW DR
Mailing Address - Street 2:
Mailing Address - City:BURKE
Mailing Address - State:VA
Mailing Address - Zip Code:22015-3935
Mailing Address - Country:US
Mailing Address - Phone:703-930-5105
Mailing Address - Fax:
Practice Address - Street 1:6455 LAKE MEADOW DR
Practice Address - Street 2:
Practice Address - City:BURKE
Practice Address - State:VA
Practice Address - Zip Code:22015-3935
Practice Address - Country:US
Practice Address - Phone:703-930-5105
Practice Address - Fax:703-930-5105
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-26
Last Update Date:2022-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1000213ES0103X
CAE5878213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty