Provider Demographics
NPI:1417935529
Name:WALLINGFORD, CRAIG R (DO)
Entity Type:Individual
Prefix:
First Name:CRAIG
Middle Name:R
Last Name:WALLINGFORD
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:180 CENTER RD
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:ME
Mailing Address - Zip Code:04027-3645
Mailing Address - Country:US
Mailing Address - Phone:207-457-1461
Mailing Address - Fax:
Practice Address - Street 1:813 MAIN ST
Practice Address - Street 2:MASSABESIC REGIONAL MEDICAL CENTER
Practice Address - City:WATERBORO
Practice Address - State:ME
Practice Address - Zip Code:04087-3006
Practice Address - Country:US
Practice Address - Phone:207-247-6131
Practice Address - Fax:207-247-6675
Is Sole Proprietor?:No
Enumeration Date:2006-01-09
Last Update Date:2013-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME999207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME120690000Medicaid
ME000973OtherANTHEM BCBS
ME010448809OtherFEDERAL ID FOR DBA AS
MEWA703412Medicare ID - Type UnspecifiedMEDICARE
MED99836Medicare UPIN