Provider Demographics
NPI:1609831361
Name:MABRY, DAVID RANDOLPH (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:RANDOLPH
Last Name:MABRY
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 1:1055 EVERGREEN CIR
Mailing Address - Street 2:
Mailing Address - City:SPRING
Mailing Address - State:TX
Mailing Address - Zip Code:77380-3602
Mailing Address - Country:US
Mailing Address - Phone:281-363-3560
Mailing Address - Fax:281-363-1643
Practice Address - Street 1:1055 EVERGREEN CIR
Practice Address - Street 2:
Practice Address - City:SPRING
Practice Address - State:TX
Practice Address - Zip Code:77380-3602
Practice Address - Country:US
Practice Address - Phone:281-363-3560
Practice Address - Fax:281-363-1643
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF8218207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
B24539Medicare UPIN
80V650Medicare ID - Type Unspecified