Provider Demographics
NPI:1093826810
Name:MOHLIE, TED R (MD)
Entity Type:Individual
Prefix:
First Name:TED
Middle Name:R
Last Name:MOHLIE
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 1:27 MILL ST
Mailing Address - Street 2:
Mailing Address - City:WALDOBORO
Mailing Address - State:ME
Mailing Address - Zip Code:04572-6013
Mailing Address - Country:US
Mailing Address - Phone:207-832-5291
Mailing Address - Fax:
Practice Address - Street 1:27 MILL ST
Practice Address - Street 2:
Practice Address - City:WALDOBORO
Practice Address - State:ME
Practice Address - Zip Code:04572-6013
Practice Address - Country:US
Practice Address - Phone:207-832-5291
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2013-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME012309207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEB86426Medicare UPIN
MEMM0914Medicare ID - Type Unspecified