Provider Demographics
NPI:1013190545
Name:PANUNCIALMAN, IAN NOEL TADEO DON DON S (MD)
Entity Type:Individual
Prefix:
First Name:IAN NOEL TADEO DON
Middle Name:DON S
Last Name:PANUNCIALMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43 WHITING HILL RD
Mailing Address - Street 2:
Mailing Address - City:BREWER
Mailing Address - State:ME
Mailing Address - Zip Code:04412-1005
Mailing Address - Country:US
Mailing Address - Phone:207-989-0550
Mailing Address - Fax:207-989-0551
Practice Address - Street 1:234 STATE ST
Practice Address - Street 2:
Practice Address - City:BREWER
Practice Address - State:ME
Practice Address - Zip Code:04412-1519
Practice Address - Country:US
Practice Address - Phone:207-989-0550
Practice Address - Fax:207-989-0551
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-06
Last Update Date:2016-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA233959207X00000X
390200000X
MEMD20887207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program