Provider Demographics
NPI:1023540309
Name:GOLDTHWAIT VISION CARE INC
Entity Type:Organization
Organization Name:GOLDTHWAIT VISION CARE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:N
Authorized Official - Last Name:GOLDTHWAIT
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:207-945-4452
Mailing Address - Street 1:663 STILLWATER AVE
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-3680
Mailing Address - Country:US
Mailing Address - Phone:207-945-4452
Mailing Address - Fax:207-945-9450
Practice Address - Street 1:663 STILLWATER AVE
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-3680
Practice Address - Country:US
Practice Address - Phone:207-945-4452
Practice Address - Fax:207-945-9450
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-28
Last Update Date:2017-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEOPT751152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME1508925363Medicaid
ME1508925363Medicaid