Provider Demographics
NPI:1366557167
Name:MAIRE, JEFFREY M (DO)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:M
Last Name:MAIRE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 PACIFIC AVE
Mailing Address - Street 2:
Mailing Address - City:AUDUBON
Mailing Address - State:IA
Mailing Address - Zip Code:50025-1056
Mailing Address - Country:US
Mailing Address - Phone:712-563-2611
Mailing Address - Fax:712-563-5298
Practice Address - Street 1:515 PACIFIC AVE
Practice Address - Street 2:
Practice Address - City:AUDUBON
Practice Address - State:IA
Practice Address - Zip Code:50025-1056
Practice Address - Country:US
Practice Address - Phone:712-563-5304
Practice Address - Fax:712-563-5275
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2018-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA3603208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0453886Medicaid
IAH54940Medicare UPIN
IA0453886Medicaid