MEDICARE: DR. JOHN LAFAYETTE DEBERRY III M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	164005	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1457314197
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOHN LAFAYETTE DEBERRY III M.D.

Provider Business Mailing Address
First Line	:	3401 ORCHARD PARK RD
Second Line	:	STE C
City	:	ORCHARD PARK
State	:	NY
Zip	:	14127-1238
Country	:	US
Telephone Number	:	716-674-3104
Fax Number	:	716-674-0666

Provider Business Practice Location Address
First Line	:	2150 WEHRLE DR
Second Line	:	STE 100
City	:	AMBST
State	:	NY
Zip	:	14221-7099
Country	:	US
Telephone Number	:	716-881-9077
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/11/2006
Last Update Date	:	11/01/2023

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