Provider Demographics
NPI:1891011581
Name:AARON J. MAYBERRY, MD, PC
Entity Type:Organization
Organization Name:AARON J. MAYBERRY, MD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:AARON
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:MAYBERRY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:505-888-3844
Mailing Address - Street 1:PO BOX 36420
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87176-6420
Mailing Address - Country:US
Mailing Address - Phone:505-888-3844
Mailing Address - Fax:505-503-8275
Practice Address - Street 1:7115 PROSPECT PL NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-4313
Practice Address - Country:US
Practice Address - Phone:505-888-3844
Practice Address - Fax:505-503-8275
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-20
Last Update Date:2012-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2001-71174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM9553053Medicaid
NM9553053Medicaid