Provider Demographics
NPI:1295237022
Name:IDAHOSURGEONS NET PC
Entity type:Organization
Organization Name:IDAHOSURGEONS NET PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:C
Authorized Official - Last Name:MAYBERRY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:858-565-0104
Mailing Address - Street 1:7910 FROST ST STE 250
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-2752
Mailing Address - Country:US
Mailing Address - Phone:858-565-0104
Mailing Address - Fax:844-213-3678
Practice Address - Street 1:7910 FROST ST STE 250
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-2752
Practice Address - Country:US
Practice Address - Phone:858-565-0104
Practice Address - Fax:844-213-3678
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-07
Last Update Date:2018-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG1511732086S0127X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma SurgeryGroup - Single Specialty