Provider Demographics
NPI:1063405975
Name:DERBENWICK, MARY JUNE (MD)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:JUNE
Last Name:DERBENWICK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 N CLYDE MORRIS BLVD
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32114-2733
Mailing Address - Country:US
Mailing Address - Phone:386-238-3244
Mailing Address - Fax:
Practice Address - Street 1:350 N CLYDE MORRIS BLVD
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-2733
Practice Address - Country:US
Practice Address - Phone:386-238-3244
Practice Address - Fax:386-238-3269
Is Sole Proprietor?:No
Enumeration Date:2005-08-25
Last Update Date:2023-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME00284872084V0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084V0102XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyVascular Neurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL64322OtherBCBS
FL1063405975OtherTRICARE
FL1063405975OtherVHN
FL1063405975OtherTRICARE
FL64322OtherBCBS
FL64322OtherBCBS
FLD57637Medicare UPIN
FL64322ZMedicare ID - Type Unspecified