Provider Demographics
NPI:1760718092
Name:MAYBERRY, DANIEL LEE (IDC)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:LEE
Last Name:MAYBERRY
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3D MARDIV DET
Mailing Address - Street 2:REGIMENTAL AID STATION
Mailing Address - City:M C B H KANEOHE BAY
Mailing Address - State:HI
Mailing Address - Zip Code:96863
Mailing Address - Country:US
Mailing Address - Phone:808-343-7780
Mailing Address - Fax:
Practice Address - Street 1:3D MARDIV DET
Practice Address - Street 2:REGIMENTAL AID STATION
Practice Address - City:M C B H KANEOHE BAY
Practice Address - State:HI
Practice Address - Zip Code:96863
Practice Address - Country:US
Practice Address - Phone:808-343-7780
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-21
Last Update Date:2009-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman