Healthcare Provider Details

I. General information

NPI: 1861467649
Provider Name (Legal Business Name): MICHAEL JUDE MAYNARD M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/23/2006
Last Update Date: 05/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

535 E 70TH ST
NEW YORK NY
10021-4872
US

IV. Provider business mailing address

535 E 70TH ST
NEW YORK NY
10021-4872
US

V. Phone/Fax

Practice location:
  • Phone: 212-628-3523
  • Fax:
Mailing address:
  • Phone: 212-628-3523
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number168756
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number168756
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: