Provider Demographics
NPI:1063450187
Name:MAYNARD, GREGORY V (DO)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:V
Last Name:MAYNARD
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2580
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65801-2580
Mailing Address - Country:US
Mailing Address - Phone:417-829-4620
Mailing Address - Fax:417-829-4316
Practice Address - Street 1:404 E ROLLA RD
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:MO
Practice Address - Zip Code:65560-1563
Practice Address - Country:US
Practice Address - Phone:573-729-6225
Practice Address - Fax:573-729-7258
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2008-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO113166207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO431560263OtherTRICARE
MOP00313978OtherRAILROAD MEDICARE
MO244666541Medicaid
MO244666541Medicaid
MO956843230Medicare PIN