Active NPI
Derick Mayberry, DDS
- Periodontics
- Hurlburt Field, FL
National Provider Identifier
1003369422
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Periodontics
- License
- 016.0123575
- Practice address
- 113 Lielmanis Ave
Hurlburt Field, FL 32544-5613 - Phone
- (850) 881-2000
- NPI assigned
- Aug 2, 2016
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Periodontics | 1223P0300X | 016.0123575 | VT | Primary |
Addresses
Primary practice location
113 Lielmanis Ave
Hurlburt Field, FL 32544-5613
Mailing address
4320 Commons Dr W Unit 5305
Destin, FL 32541-8660
Phone (575) 956-5112
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 016.0123575 | VT | MD | Periodontist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1470096000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1598918400000",
"number": "1003369422",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "4320 COMMONS DR W UNIT 5305",
"city": "DESTIN",
"state": "FL",
"postal_code": "325418660",
"telephone_number": "575-956-5112"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "113 LIELMANIS AVE",
"city": "HURLBURT FIELD",
"state": "FL",
"postal_code": "325445613",
"telephone_number": "850-881-2000"
}
],
"practiceLocations": [],
"basic": {
"last_name": "MAYBERRY",
"first_name": "DERICK",
"credential": "DDS",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2016-08-02",
"last_updated": "2020-09-01",
"certification_date": "2020-09-01",
"status": "A"
},
"taxonomies": [
{
"code": "1223P0300X",
"taxonomy_group": "",
"desc": "Dentist, Periodontics",
"state": "VT",
"license": "016.0123575",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Hurlburt Field, FL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 1, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.