Provider Demographics
NPI:1992792014
Name:MAPLE, JEFFREY E (MD)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:E
Last Name:MAPLE
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:PO BOX 919
Mailing Address - Street 2:
Mailing Address - City:ILWACO
Mailing Address - State:WA
Mailing Address - Zip Code:98624-0919
Mailing Address - Country:US
Mailing Address - Phone:360-642-2662
Mailing Address - Fax:360-642-2663
Practice Address - Street 1:117 SPRUCE ST
Practice Address - Street 2:
Practice Address - City:ILWACO
Practice Address - State:WA
Practice Address - Zip Code:98624
Practice Address - Country:US
Practice Address - Phone:360-642-2662
Practice Address - Fax:360-642-2663
Is Sole Proprietor?:No
Enumeration Date:2005-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00035420207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1012MAOtherBCBS
WA8319055Medicaid
WA178545OtherL&I
H755391Medicare ID - Type Unspecified
WA178545OtherL&I