Provider Demographics
NPI:1629019260
Name:MAYBERRY, ANDREW W (MD)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:W
Last Name:MAYBERRY
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 1:1205 N F AVE
Mailing Address - Street 2:
Mailing Address - City:DOUGLAS
Mailing Address - State:AZ
Mailing Address - Zip Code:85607-1920
Mailing Address - Country:US
Mailing Address - Phone:520-364-6852
Mailing Address - Fax:520-364-4261
Practice Address - Street 1:890 W 4TH ST
Practice Address - Street 2:
Practice Address - City:BENSON
Practice Address - State:AZ
Practice Address - Zip Code:85602-6437
Practice Address - Country:US
Practice Address - Phone:520-586-3664
Practice Address - Fax:520-586-3486
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2020-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ28086207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ502056Medicaid
AZG81573Medicare UPIN
AZZ60754Medicare PIN