Provider Demographics
NPI:1124275235
Name:MAYBERRY, KATHRYN A (OD)
Entity type:Individual
Prefix:DR
First Name:KATHRYN
Middle Name:A
Last Name:MAYBERRY
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:KATHRYN
Other - Middle Name:A
Other - Last Name:HOWARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:812 N ONE MILE RD
Mailing Address - Street 2:
Mailing Address - City:DEXTER
Mailing Address - State:MO
Mailing Address - Zip Code:63841-1034
Mailing Address - Country:US
Mailing Address - Phone:573-614-5393
Mailing Address - Fax:573-614-5639
Practice Address - Street 1:812 N ONE MILE RD
Practice Address - Street 2:
Practice Address - City:DEXTER
Practice Address - State:MO
Practice Address - Zip Code:63841-1034
Practice Address - Country:US
Practice Address - Phone:573-614-5393
Practice Address - Fax:573-614-5639
Is Sole Proprietor?:No
Enumeration Date:2008-08-20
Last Update Date:2012-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009016930152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1124275235Medicaid
MA1184OtherMEDICARE PTAN