Provider Demographics
NPI:1205863156
Name:JOHANNESSON, INGA S (DO)
Entity Type:Individual
Prefix:DR
First Name:INGA
Middle Name:S
Last Name:JOHANNESSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:301C US ROUTE 1
Mailing Address - Street 2:
Mailing Address - City:SCARBOROUGH
Mailing Address - State:ME
Mailing Address - Zip Code:04074-9701
Mailing Address - Country:US
Mailing Address - Phone:207-396-8600
Mailing Address - Fax:207-396-8632
Practice Address - Street 1:193 MAIN ST
Practice Address - Street 2:SUITE 1
Practice Address - City:NORWAY
Practice Address - State:ME
Practice Address - Zip Code:04268-5645
Practice Address - Country:US
Practice Address - Phone:207-330-3950
Practice Address - Fax:207-330-3955
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2013-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME1827207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME419020099Medicaid
MEI13739Medicare UPIN
ME084703Medicare PIN
ME419020099Medicaid