Basic Information
| Provider Information | |||||||||
| NPI: | 1962415000 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MAYNARD | ||||||||
| FirstName: | DEAN | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2610 HOSPITAL RD | ||||||||
| Address2: | |||||||||
| City: | GOLDSBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275349423 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9197314809 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3601 SW 160TH AVE | ||||||||
| Address2: | SUITE 250 | ||||||||
| City: | MIRAMAR | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330276308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9543994645 | ||||||||
| FaxNumber: | 8558552792 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/13/2006 | ||||||||
| LastUpdateDate: | 06/28/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 26848 | SC | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 2009-00027 | NC | N | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 268481 | 05 | SC | MEDICAID |