Healthcare Provider Details

I. General information

NPI: 1629019260
Provider Name (Legal Business Name): ANDREW W MAYBERRY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2006
Last Update Date: 06/26/2020
Certification Date: 06/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

890 W 4TH ST
BENSON AZ
85602-6437
US

IV. Provider business mailing address

1205 N F AVE
DOUGLAS AZ
85607-1920
US

V. Phone/Fax

Practice location:
  • Phone: 520-586-3664
  • Fax: 520-586-3486
Mailing address:
  • Phone: 520-364-6852
  • Fax: 520-364-4261

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number28086
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: