Individual
KURT R MAYBERRY
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
450 E MAIN ST, REXBURG, ID 83440-2048
(208) 356-3691
Mailing address
450 E MAIN ST, PO BOX 310, REXBURG, ID 83440-2048
(208) 356-3691
Taxonomy
Speciality
Code
Description
License number
State
207P00000X
Emergency Medicine Physician
Primary
M8416
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000010139001
BLUE SHIELD OF IDAHO #
ID
01
—
028692
BLUE CROSS OF IDAHO #
ID
01
—
M8416
STATE LICENSE #
ID
Enumeration date
09/27/2006
Last updated
07/09/2007
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