Provider Demographics
NPI:1043425812
Name:MAYNARD, JANET WILLOUGHBY (MD)
Entity Type:Individual
Prefix:DR
First Name:JANET
Middle Name:WILLOUGHBY
Last Name:MAYNARD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 64264
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-4264
Mailing Address - Country:US
Mailing Address - Phone:410-558-5238
Mailing Address - Fax:
Practice Address - Street 1:5200 EASTERN AVE
Practice Address - Street 2:MASON F. LORD BUILDING CENTER TOWER, SUITE 4100
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21224-2734
Practice Address - Country:US
Practice Address - Phone:410-614-3368
Practice Address - Fax:410-550-2072
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-14
Last Update Date:2011-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC122414207R00000X
MDD71282207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD036817200Medicaid
NC3400030Medicaid
NC3400030Medicaid
NC82404DMedicare UPIN