Provider Demographics
NPI:1043253636
Name:ERTMAN, DOUGLAS GARDNER (MD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:GARDNER
Last Name:ERTMAN
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 1:144 STATE ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04101-3776
Mailing Address - Country:US
Mailing Address - Phone:207-879-3000
Mailing Address - Fax:
Practice Address - Street 1:385 ROUTE 1
Practice Address - Street 2:
Practice Address - City:YARMOUTH
Practice Address - State:ME
Practice Address - Zip Code:04096-6729
Practice Address - Country:US
Practice Address - Phone:207-535-1200
Practice Address - Fax:207-535-1249
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2012-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME014987207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEF39176Medicare UPIN
MEMM7819Medicare PIN