Provider Demographics
NPI:1558597690
Name:MAYNE, JEFFREY DAVID (MD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:DAVID
Last Name:MAYNE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1351 ROUTE 55
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LAGRANGEVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12540-5108
Mailing Address - Country:US
Mailing Address - Phone:845-475-9661
Mailing Address - Fax:845-475-9938
Practice Address - Street 1:6511 SPRING BROOK AVE
Practice Address - Street 2:
Practice Address - City:RHINEBECK
Practice Address - State:NY
Practice Address - Zip Code:12572-3709
Practice Address - Country:US
Practice Address - Phone:845-876-3001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-03
Last Update Date:2017-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY261136208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04536710Medicaid
NY04536710Medicaid