Provider Demographics
NPI:1891886479
Name:MAYBERRY, KURT R (MD)
Entity type:Individual
Prefix:
First Name:KURT
Middle Name:R
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 1:450 E MAIN ST
Mailing Address - Street 2:PO BOX 310
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-2048
Mailing Address - Country:US
Mailing Address - Phone:208-356-3691
Mailing Address - Fax:
Practice Address - Street 1:450 E MAIN ST
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-2048
Practice Address - Country:US
Practice Address - Phone:208-356-3691
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM8416207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID028692OtherBLUE CROSS OF IDAHO #
ID000010139001OtherBLUE SHIELD OF IDAHO #
IDM8416OtherSTATE LICENSE #
ID028692OtherBLUE CROSS OF IDAHO #
ID1104006Medicare ID - Type UnspecifiedCIGNA MEDICARE #