Provider Demographics
NPI:1003096017
Name:DANIEL MARK MERSON
Entity Type:Organization
Organization Name:DANIEL MARK MERSON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:MERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:207-878-5042
Mailing Address - Street 1:1250 FOREST AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103-1889
Mailing Address - Country:US
Mailing Address - Phone:207-878-5042
Mailing Address - Fax:207-878-5043
Practice Address - Street 1:1250 FOREST AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04103-1889
Practice Address - Country:US
Practice Address - Phone:207-878-5042
Practice Address - Fax:207-878-5043
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-07
Last Update Date:2008-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEME1373207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
E82051Medicare UPIN