Provider Demographics
NPI:1538241567
Name:MAYBERRY, CARL C (PHYSICIANS ASSISTANT)
Entity type:Individual
Prefix:
First Name:CARL
Middle Name:C
Last Name:MAYBERRY
Suffix:
Gender:M
Credentials:PHYSICIANS ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4900 FANNIN ST
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77004-5706
Mailing Address - Country:US
Mailing Address - Phone:713-446-3018
Mailing Address - Fax:713-526-4680
Practice Address - Street 1:4900 FANNIN ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77004-5706
Practice Address - Country:US
Practice Address - Phone:713-526-9821
Practice Address - Fax:713-526-4680
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2008-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA01360363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8C7359Medicare PIN