Provider Demographics
NPI:1427323245
Name:MAYBORODA, IGGY (ND)
Entity type:Individual
Prefix:DR
First Name:IGGY
Middle Name:
Last Name:MAYBORODA
Suffix:
Gender:M
Credentials:ND
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4149 E BETSY LN
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85296-9623
Mailing Address - Country:US
Mailing Address - Phone:480-600-0807
Mailing Address - Fax:
Practice Address - Street 1:4149 E BETSY LN
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85296-9623
Practice Address - Country:US
Practice Address - Phone:480-600-0807
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-12
Last Update Date:2013-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT099.0084660175F00000X
CAND-535175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT099.0084660OtherCREDENTIAL #
CANDF-535OtherSTATE LICENSE