Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 213EP1101X | Primary Podiatric Medicine | PO2788 | FL |
N | 111NR0200X | Radiology | JR3863700 | FL |
N | 213ER0200X | Radiology | JR3863700 | FL |
NPI | 1023079688 |
---|---|
Provider Name | Dr. George Otto Mabry Jr |
First Address | Indian Harbour Beach, FL 32937-4930 |
Second Address | Indian Harbour Beach, FL 32937-4930 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 31/03/2006 |
Last Update Date | 27/12/2016 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0380220001 | CIGNA ID # (01) | FL |
2900719 | AETNA HMO/QPOS ID # (01) | FL |
340672500 | (05) | FL |
65612 | BCBS ID (01) | FL |
7781081 | AETNA PPO/POS ID # (01) | FL |
U75523 | (02) | FL |