Provider Demographics
NPI:1063543056
Name:MAYBERRY, CLIFTON A (MD)
Entity type:Individual
Prefix:
First Name:CLIFTON
Middle Name:A
Last Name:MAYBERRY
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 1:2750 E WASHINGTON BLVD
Mailing Address - Street 2:STE 330
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91107-1448
Mailing Address - Country:US
Mailing Address - Phone:626-797-9883
Mailing Address - Fax:626-797-9853
Practice Address - Street 1:2750 E WASHINGTON BLVD
Practice Address - Street 2:STE 330
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91107-1448
Practice Address - Country:US
Practice Address - Phone:626-797-9883
Practice Address - Fax:626-797-9853
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG43796174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0029750Medicaid
CA100002889OtherRAILROAD MEDICARE
CAGR0029750Medicaid