Provider Demographics
NPI:1477572394
Name:MAYBERRY, MELISSA J (MD)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:J
Last Name:MAYBERRY
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 1:2446 W WHITTIER BLVD
Mailing Address - Street 2:
Mailing Address - City:MONTEBELLO
Mailing Address - State:CA
Mailing Address - Zip Code:90640-3041
Mailing Address - Country:US
Mailing Address - Phone:323-728-5500
Mailing Address - Fax:323-728-4408
Practice Address - Street 1:2446 W WHITTIER BLVD
Practice Address - Street 2:
Practice Address - City:MONTEBELLO
Practice Address - State:CA
Practice Address - Zip Code:90640-3041
Practice Address - Country:US
Practice Address - Phone:323-728-5500
Practice Address - Fax:323-728-4408
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2007-08-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA71074207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAH58647Medicare UPIN