Provider Demographics
NPI:1457314197
Name:DEBERRY, JOHN LAFAYETTE III (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:LAFAYETTE
Last Name:DEBERRY
Suffix:III
Gender:M
Credentials:MD
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Mailing Address - Street 1:3401 ORCHARD PARK RD
Mailing Address - Street 2:STE C
Mailing Address - City:ORCHARD PARK
Mailing Address - State:NY
Mailing Address - Zip Code:14127-1238
Mailing Address - Country:US
Mailing Address - Phone:716-674-3104
Mailing Address - Fax:716-674-0666
Practice Address - Street 1:2150 WEHRLE DR
Practice Address - Street 2:STE 100
Practice Address - City:AMBST
Practice Address - State:NY
Practice Address - Zip Code:14221-7099
Practice Address - Country:US
Practice Address - Phone:716-881-9077
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-11
Last Update Date:2023-11-01
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NY164005174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01023385Medicaid