Provider Demographics
NPI:1619970381
Name:MAYNARD, PHILIP A (DPM)
Entity Type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:A
Last Name:MAYNARD
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:416 N MINNESOTA AVE
Mailing Address - Street 2:
Mailing Address - City:HASTINGS
Mailing Address - State:NE
Mailing Address - Zip Code:68901-5254
Mailing Address - Country:US
Mailing Address - Phone:402-462-2788
Mailing Address - Fax:402-462-4783
Practice Address - Street 1:416 N MINNESOTA AVE
Practice Address - Street 2:
Practice Address - City:HASTINGS
Practice Address - State:NE
Practice Address - Zip Code:68901-5254
Practice Address - Country:US
Practice Address - Phone:402-462-2788
Practice Address - Fax:402-462-4783
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-24
Last Update Date:2013-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE159213ES0131X, 213E00000X
IA00365213ES0131X, 213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE02513OtherBC-BS OF NE
NE480021803OtherRAILROAD MEDICARE
NE1197710001OtherDME NORIDAN
NE47062581300Medicaid
NET40102Medicare UPIN
NE091232Medicare PIN