Provider Demographics
NPI:1043368160
Name:PULVER, MITCHELL (MD)
Entity Type:Individual
Prefix:
First Name:MITCHELL
Middle Name:
Last Name:PULVER
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 1:153 PARK ROW
Mailing Address - Street 2:SUITE B
Mailing Address - City:BRUNSWICK
Mailing Address - State:ME
Mailing Address - Zip Code:04011-2053
Mailing Address - Country:US
Mailing Address - Phone:207-729-8391
Mailing Address - Fax:
Practice Address - Street 1:153 PARK ROW
Practice Address - Street 2:SUITE B
Practice Address - City:BRUNSWICK
Practice Address - State:ME
Practice Address - Zip Code:04011-2053
Practice Address - Country:US
Practice Address - Phone:207-729-8391
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME0158352084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME226720000Medicaid
B73040Medicare UPIN
ME226720000Medicaid