Healthcare Provider Details

I. General information

NPI: 1992792014
Provider Name (Legal Business Name): JEFFREY E MAPLE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

117 SPRUCE ST
ILWACO WA
98624
US

IV. Provider business mailing address

PO BOX 919
ILWACO WA
98624-0919
US

V. Phone/Fax

Practice location:
  • Phone: 360-642-2662
  • Fax: 360-642-2663
Mailing address:
  • Phone: 360-642-2662
  • Fax: 360-642-2663

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD00035420
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: