Provider Demographics
NPI:1790079499
Name:MAYNARD, MATTHEW DEAN (DO)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:DEAN
Last Name:MAYNARD
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:830 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-4034
Mailing Address - Country:US
Mailing Address - Phone:315-779-5244
Mailing Address - Fax:
Practice Address - Street 1:830 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-4034
Practice Address - Country:US
Practice Address - Phone:315-786-4813
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-31
Last Update Date:2018-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY269418207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03983768Medicaid