Active NPI
Mary Jennifer Derebery
- Otolaryngic Allergy Physician
- Los Angeles, CA
National Provider Identifier
1457440992
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Otolaryngic Allergy Physician
- License
- C42073
- Practice address
- 2100 W 3Rd St
Suite 111
Los Angeles, CA 90057-1944 - Phone
- (213) 483-9930
- Fax
- (213) 483-0905
- NPI assigned
- Oct 12, 2006
- Sex
- Female
- 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 |
|---|---|---|---|---|
| Otolaryngic Allergy Physician | 207YX0602X | C42073 | CA | Primary |
Addresses
Primary practice location
2100 W 3Rd St
Suite 111
Los Angeles, CA 90057-1944
Mailing address
2100 W 3Rd St
Suite 111
Los Angeles, CA 90057-1944
Phone (213) 483-9930
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)
- Enrolled
- Credentials
- Doctor of Medicine
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| C42073 | CA | MD | Otolaryngic Allergy Physician |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1160611200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1376524800000",
"number": "1457440992",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "2100 W 3RD ST",
"address_2": "SUITE 111",
"city": "LOS ANGELES",
"state": "CA",
"postal_code": "900571944",
"telephone_number": "213-483-9930",
"fax_number": "213-483-0905"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "2100 W 3RD ST",
"address_2": "SUITE 111",
"city": "LOS ANGELES",
"state": "CA",
"postal_code": "900571944",
"telephone_number": "213-483-9930",
"fax_number": "213-483-0905"
}
],
"practiceLocations": [],
"basic": {
"last_name": "DEREBERY",
"first_name": "MARY",
"middle_name": "JENNIFER",
"name_prefix": "Dr.",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2006-10-12",
"last_updated": "2013-08-15",
"status": "A"
},
"taxonomies": [
{
"code": "207YX0602X",
"taxonomy_group": "",
"desc": "Otolaryngology, Otolaryngic Allergy",
"state": "CA",
"license": "C42073",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Los Angeles, CA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 15, 2013; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.