Provider Demographics
NPI:1861467649
Name:MAYNARD, MICHAEL JUDE (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JUDE
Last Name:MAYNARD
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 1:535 E 70TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10021-4872
Mailing Address - Country:US
Mailing Address - Phone:212-628-3523
Mailing Address - Fax:
Practice Address - Street 1:535 E 70TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021-4872
Practice Address - Country:US
Practice Address - Phone:212-628-3523
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-23
Last Update Date:2008-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY168756207X00000X, 207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02694062Medicaid
NY65268ANX51OtherMEDICARE PTAN
NYWANX51OtherMEDICARE GROUP NUMBER
NYF32891Medicare UPIN
NY02694062Medicaid