Provider Demographics
NPI:1205884202
Name:MABERY, JARED BLAINE (MD)
Entity type:Individual
Prefix:
First Name:JARED
Middle Name:BLAINE
Last Name:MABERY
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 1:5107 WATERFORD CT
Mailing Address - Street 2:
Mailing Address - City:TEMPLE
Mailing Address - State:TX
Mailing Address - Zip Code:76502-7317
Mailing Address - Country:US
Mailing Address - Phone:254-742-0980
Mailing Address - Fax:
Practice Address - Street 1:2400 ROUND ROCK AVE
Practice Address - Street 2:
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78681-4004
Practice Address - Country:US
Practice Address - Phone:512-341-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2011-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK7809207PE0004X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX122080805Medicaid
TX122080807Medicaid
TXP00967092OtherMEDICARE RAILROAD
TXP00967092OtherMEDICARE RAILROAD
TX8A1483Medicare ID - Type Unspecified
TXTXB113497Medicare PIN