Provider Demographics
NPI:1043226129
Name:BOLDUC, MARK EUGENE (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:EUGENE
Last Name:BOLDUC
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 1:325 KENNEDY MEMORIAL DR # B
Mailing Address - Street 2:
Mailing Address - City:WATERVILLE
Mailing Address - State:ME
Mailing Address - Zip Code:04901-4517
Mailing Address - Country:US
Mailing Address - Phone:207-872-7171
Mailing Address - Fax:207-877-7268
Practice Address - Street 1:325 KENNEDY MEMORIAL DR # B
Practice Address - Street 2:
Practice Address - City:WATERVILLE
Practice Address - State:ME
Practice Address - Zip Code:04901-4517
Practice Address - Country:US
Practice Address - Phone:207-872-7171
Practice Address - Fax:207-877-7268
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2014-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME011486208600000X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEM101030OtherCIGNA
ME039918OtherANTHEM BLUE CROSS
ME015391Medicare ID - Type Unspecified
ME01539101Medicare PIN
ME01539102Medicare PIN
ME039918OtherANTHEM BLUE CROSS