MEDICARE: DR. MARY JENNIFER DEREBERY

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	207YX0602X	Otolaryngic Allergy Physician	C42073	CA

General Provider Information

NPI Number	:	1457440992
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARY JENNIFER DEREBERY

Provider Business Mailing Address
First Line	:	2100 W 3RD ST
Second Line	:	SUITE 111
City	:	LOS ANGELES
State	:	CA
Zip	:	90057-1944
Country	:	US
Telephone Number	:	213-483-9930
Fax Number	:	213-483-0905

Provider Business Practice Location Address
First Line	:	2100 W 3RD ST
Second Line	:	SUITE 111
City	:	LOS ANGELES
State	:	CA
Zip	:	90057-1944
Country	:	US
Telephone Number	:	213-483-9930
Fax Number	:	213-483-0905

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

Provider Enumeration Date	:	10/12/2006
Last Update Date	:	08/15/2013

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