Provider Demographics
NPI:1194798421
Name:MAYBERRY, JOSEPH J (DO)
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:J
Last Name:MAYBERRY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 HUNTINGWOOD DR
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:PA
Mailing Address - Zip Code:17602-1390
Mailing Address - Country:US
Mailing Address - Phone:717-951-4054
Mailing Address - Fax:
Practice Address - Street 1:105 HUNTINGWOOD DR
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:PA
Practice Address - Zip Code:17602-1390
Practice Address - Country:US
Practice Address - Phone:717-464-4099
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-08
Last Update Date:2019-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS003136L207P00000X, 207PE0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0005XAllopathic & Osteopathic PhysiciansEmergency MedicineUndersea and Hyperbaric Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA000683795 0010Medicaid
B36516Medicare UPIN
PA000683795 0010Medicaid