Provider Demographics
NPI:1316922545
Name:ABERNATHY, MABRA GLENN (MD)
Entity type:Individual
Prefix:DR
First Name:MABRA
Middle Name:GLENN
Last Name:ABERNATHY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:M. GLENN
Other - Middle Name:G
Other - Last Name:ABERNATHY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:200 HAWKINS DR
Mailing Address - Street 2:
Mailing Address - City:IOWA CITY
Mailing Address - State:IA
Mailing Address - Zip Code:52242-1009
Mailing Address - Country:US
Mailing Address - Phone:319-384-7000
Mailing Address - Fax:319-467-2814
Practice Address - Street 1:920 E 2ND AVE STE 201
Practice Address - Street 2:
Practice Address - City:CORALVILLE
Practice Address - State:IA
Practice Address - Zip Code:52241-2225
Practice Address - Country:US
Practice Address - Phone:319-384-7000
Practice Address - Fax:319-467-2814
Is Sole Proprietor?:No
Enumeration Date:2005-12-09
Last Update Date:2018-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA37536207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1316922545OtherMEDICAID.... UIQC.... OCTC.....NL.....SEIC
IA1184673972OtherWELLMARK
IA1316922545Medicaid
SC103989Medicaid
IA1316922545OtherMEDICAID.... UIQC.... OCTC.....NL.....SEIC
SCD179007564Medicare ID - Type Unspecified
SC103989Medicaid
IAI1421006Medicare PIN