1467565671 NPI number — DR. JENNIFER PURDY MAYBERRY MD

Table of content: DR. JENNIFER PURDY MAYBERRY MD (NPI 1467565671)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467565671 NPI number — DR. JENNIFER PURDY MAYBERRY MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MAYBERRY
Provider First Name:
JENNIFER
Provider Middle Name:
PURDY
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PURDY
Provider Other First Name:
MARY
Provider Other Middle Name:
JENNIFER
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1467565671
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
21874 NE PARK LANE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FAIRVIEW
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97204
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-253-1105
Provider Business Mailing Address Fax Number:
503-535-8398

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
233 NE 102ND AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97220
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-253-1105
Provider Business Practice Location Address Fax Number:
503-535-8398
Provider Enumeration Date:
08/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X , with the licence number:  MD24376 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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