Provider Demographics
NPI:1235146481
Name:MAXWELL, DAMIAN (MD)
Entity Type:Individual
Prefix:DR
First Name:DAMIAN
Middle Name:
Last Name:MAXWELL
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:PO BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-343-6050
Mailing Address - Fax:239-343-9909
Practice Address - Street 1:16230 SUMMERLIN RD STE 215
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33908-5769
Practice Address - Country:US
Practice Address - Phone:239-343-6050
Practice Address - Fax:239-343-9909
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV22268208600000X
FLME1298522086S0120X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVP00358613OtherRAILROAD MEDICARE
WV3810006087Medicaid
FL020940500Medicaid
FL020940500Medicaid
WVMA6034531Medicare PIN