Provider Demographics
NPI:1295962066
Name:DERREBERRY, TODD MICHAEL (MD)
Entity type:Individual
Prefix:DR
First Name:TODD
Middle Name:MICHAEL
Last Name:DERREBERRY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:2554 LEWISVILLE CLEMMONS RD STE 207
Mailing Address - Street 2:
Mailing Address - City:CLEMMONS
Mailing Address - State:NC
Mailing Address - Zip Code:27012-9752
Mailing Address - Country:US
Mailing Address - Phone:336-223-8220
Mailing Address - Fax:339-207-0143
Practice Address - Street 1:2554 LEWISVILLE CLEMMONS RD STE 207
Practice Address - Street 2:
Practice Address - City:CLEMMONS
Practice Address - State:NC
Practice Address - Zip Code:27012-9752
Practice Address - Country:US
Practice Address - Phone:336-223-8220
Practice Address - Fax:339-207-0143
Is Sole Proprietor?:No
Enumeration Date:2009-06-18
Last Update Date:2020-06-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WV257362084P0805X, 2084P0800X
NC2015-008942084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric Psychiatry