Provider Demographics
NPI:1245575240
Name:BARRY, MAXWELL JOHN
Entity Type:Individual
Prefix:MR
First Name:MAXWELL
Middle Name:JOHN
Last Name:BARRY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1801 VICENTE ST
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94116-2923
Mailing Address - Country:US
Mailing Address - Phone:415-681-3211
Mailing Address - Fax:
Practice Address - Street 1:1801 VICENTE ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94116-2923
Practice Address - Country:US
Practice Address - Phone:415-681-3211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-01
Last Update Date:2014-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1245575240172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker