Healthcare Provider Details

I. General information

NPI: 1790436632
Provider Name (Legal Business Name): STEVEN LEGRAND MAYBERRY DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/12/2022
Last Update Date: 08/24/2026
Certification Date: 08/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

99TH MEDICAL GROUP 4700 LAS VEGAS BLVD
NORTH NELLIS AFB NV
89191-6601
US

IV. Provider business mailing address

4700 LAS VEGAS BLVD N
NELLIS AFB NV
89191-6600
US

V. Phone/Fax

Practice location:
  • Phone: 702-653-2273
  • Fax:
Mailing address:
  • Phone: 702-653-2201
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number5101028896
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: