Healthcare Provider Details

I. General information

NPI: 1417075300
Provider Name (Legal Business Name): BRIAN J KERBYSON D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2007
Last Update Date: 10/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2450 TAMIAMI TRL SUITE A
PT CHARLOTTE FL
33952-3922
US

IV. Provider business mailing address

3434 HANCOCK BRIDGE PKWY
N FT MYERS FL
33903-7094
US

V. Phone/Fax

Practice location:
  • Phone: 941-627-7204
  • Fax: 941-627-6066
Mailing address:
  • Phone: 877-856-3774
  • Fax: 239-599-2625

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number10734
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: