Provider Demographics
NPI:1033777362
Name:MLADUCKY, JOHN (PA-C)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:MLADUCKY
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:56 PENNELL AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103-2076
Mailing Address - Country:US
Mailing Address - Phone:920-288-1384
Mailing Address - Fax:
Practice Address - Street 1:300 MAIN ST
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ME
Practice Address - Zip Code:04240-7027
Practice Address - Country:US
Practice Address - Phone:207-795-0111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-01
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPA1957208D00000X, 208M00000X, 207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist