Provider Demographics
NPI:1295733459
Name:MAYBURY, KENNETH BRUERE (MD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:BRUERE
Last Name:MAYBURY
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 1:2250 HAYES ST STE 504
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94117-1078
Mailing Address - Country:US
Mailing Address - Phone:415-422-0998
Mailing Address - Fax:415-422-0903
Practice Address - Street 1:2250 HAYES ST STE 504
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94117-1078
Practice Address - Country:US
Practice Address - Phone:415-422-0998
Practice Address - Fax:415-422-0903
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-12
Last Update Date:2024-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG77043207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G770430Medicaid
G16981Medicare UPIN