Healthcare Provider Details

I. General information

NPI: 1740272723
Provider Name (Legal Business Name): BRYAN VYVERBERG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/17/2005
Last Update Date: 02/25/2025
Certification Date: 02/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

812 CREIGHTON RD
PENSACOLA FL
32504-7028
US

IV. Provider business mailing address

8845 LORRAINE RD
GULFPORT MS
39503-5042
US

V. Phone/Fax

Practice location:
  • Phone: 850-564-6644
  • Fax: 866-740-0655
Mailing address:
  • Phone: 228-277-1771
  • Fax: 866-740-0655

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number10017
License Number StateHI
# 2
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number22206
License Number StateMS
# 3
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberME169348
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: