Provider Demographics
NPI:1609877570
Name:MAYNARD, BOBBY L (MD)
Entity Type:Individual
Prefix:
First Name:BOBBY
Middle Name:L
Last Name:MAYNARD
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 1:1400 29TH ST S
Mailing Address - Street 2:
Mailing Address - City:GREAT FALLS
Mailing Address - State:MT
Mailing Address - Zip Code:59405
Mailing Address - Country:US
Mailing Address - Phone:406-454-2171
Mailing Address - Fax:406-771-3021
Practice Address - Street 1:1101 26TH ST SOUTH
Practice Address - Street 2:
Practice Address - City:GREAT FALLS
Practice Address - State:MT
Practice Address - Zip Code:59405
Practice Address - Country:US
Practice Address - Phone:406-455-5319
Practice Address - Fax:406-455-5303
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2010-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT5341208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0068887Medicaid
MT0068887Medicaid
MT000009535Medicare ID - Type Unspecified
MT011003745Medicare PIN