Provider Demographics
NPI:1740272723
Name:VYVERBERG, BRYAN (MD)
Entity type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:
Last Name:VYVERBERG
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8845 LORRAINE RD
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39503-5042
Mailing Address - Country:US
Mailing Address - Phone:228-277-1771
Mailing Address - Fax:866-740-0655
Practice Address - Street 1:812 CREIGHTON RD
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32504-7028
Practice Address - Country:US
Practice Address - Phone:850-564-6644
Practice Address - Fax:866-740-0655
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-17
Last Update Date:2025-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI100172084P0804X
MS222062084P0804X
FLME1693482084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS06322869Medicaid