Provider Demographics
NPI:1790436632
Name:MAYBERRY, STEVEN LEGRAND (DO)
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:LEGRAND
Last Name:MAYBERRY
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 1:4700 LAS VEGAS BLVD N
Mailing Address - Street 2:
Mailing Address - City:NELLIS AFB
Mailing Address - State:NV
Mailing Address - Zip Code:89191-6600
Mailing Address - Country:US
Mailing Address - Phone:702-653-2273
Mailing Address - Fax:
Practice Address - Street 1:99TH MEDICAL GROUP
Practice Address - Street 2:4700 LAS VEGAS BLVD
Practice Address - City:NORTH NELLIS AFB
Practice Address - State:NV
Practice Address - Zip Code:89191-6601
Practice Address - Country:US
Practice Address - Phone:702-653-2273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-12
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program