Healthcare Provider Details

I. General information

NPI: 1649276247
Provider Name (Legal Business Name): IRVIN CARLYLE BEMBRY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/28/2005
Last Update Date: 12/01/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

413 5TH AVE NW
JASPER FL
32052-7800
US

IV. Provider business mailing address

PO BOX 1028
JASPER FL
32052-1028
US

V. Phone/Fax

Practice location:
  • Phone: 386-792-2985
  • Fax: 386-792-0833
Mailing address:
  • Phone: 386-792-2985
  • Fax: 386-792-0833

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number22041
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: