Provider Demographics
NPI:1023079688
Name:MABRY JR, GEORGE OTTO (DPM)
Entity type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:OTTO
Last Name:MABRY JR
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2194 HWY A1A
Mailing Address - Street 2:SUITE 108
Mailing Address - City:INDIAN HARBOUR BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32937-4930
Mailing Address - Country:US
Mailing Address - Phone:321-777-9559
Mailing Address - Fax:321-777-9558
Practice Address - Street 1:2194 HWY A1A
Practice Address - Street 2:SUITE 108
Practice Address - City:INDIAN HARBOUR BEACH
Practice Address - State:FL
Practice Address - Zip Code:32937-4930
Practice Address - Country:US
Practice Address - Phone:321-777-9559
Practice Address - Fax:321-777-9558
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-31
Last Update Date:2016-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO2788213EP1101X, 213EP1101X
FLJR3863700213ER0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
No213ER0200XPodiatric Medicine & Surgery Service ProvidersPodiatristRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL65612OtherBCBS ID
FL2900719OtherAETNA HMO/QPOS ID #
FL7781081OtherAETNA PPO/POS ID #
FL340672500Medicaid
FL0380220001OtherCIGNA ID #
FL340672500Medicaid
FL65612OtherBCBS ID
FLE2668AMedicare PIN