Provider Demographics
NPI:1649276247
Name:BEMBRY, IRVIN CARLYLE (MD)
Entity type:Individual
Prefix:
First Name:IRVIN
Middle Name:CARLYLE
Last Name:BEMBRY
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:PO BOX 1028
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:FL
Mailing Address - Zip Code:32052-1028
Mailing Address - Country:US
Mailing Address - Phone:386-792-2985
Mailing Address - Fax:386-792-0833
Practice Address - Street 1:413 5TH AVE NW
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:FL
Practice Address - Zip Code:32052-7800
Practice Address - Country:US
Practice Address - Phone:386-792-2985
Practice Address - Fax:386-792-0833
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-28
Last Update Date:2009-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL22041207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL055712900Medicaid
18882Medicare ID - Type Unspecified
FL055712900Medicaid