Provider Demographics
NPI:1407086473
Name:MAYBERRY, JEFFRIE NEIL (IDMT)
Entity Type:Individual
Prefix:MR
First Name:JEFFRIE
Middle Name:NEIL
Last Name:MAYBERRY
Suffix:
Gender:M
Credentials:IDMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:90 HOPE DR BLDG 6000
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME A F B
Mailing Address - State:ID
Mailing Address - Zip Code:83648-1062
Mailing Address - Country:US
Mailing Address - Phone:208-828-7100
Mailing Address - Fax:
Practice Address - Street 1:90 HOPE DR BLDG 6000
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME A F B
Practice Address - State:ID
Practice Address - Zip Code:83648-1062
Practice Address - Country:US
Practice Address - Phone:208-828-7100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-23
Last Update Date:2009-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians