Provider Demographics
NPI:1275521650
Name:SELF, CYNTHIA AMANDA (MD)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:AMANDA
Last Name:SELF
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 HAMMOND ST # A
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-4378
Mailing Address - Country:US
Mailing Address - Phone:207-947-6743
Mailing Address - Fax:207-945-4397
Practice Address - Street 1:900 HAMMOND ST # A
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-4378
Practice Address - Country:US
Practice Address - Phone:207-947-6743
Practice Address - Fax:207-945-4397
Is Sole Proprietor?:No
Enumeration Date:2005-10-11
Last Update Date:2018-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMD16811207WX0120X
ME016811207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No207WX0120XAllopathic & Osteopathic PhysiciansOphthalmologyCornea and External Diseases Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME431809499Medicaid
MEH61839Medicare UPIN
MEME1363Medicare PIN