Provider Demographics
NPI:1437358157
Name:DERSCH, CANDICE M (MD)
Entity Type:Individual
Prefix:
First Name:CANDICE
Middle Name:M
Last Name:DERSCH
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 1:301 US ROUTE 1
Mailing Address - Street 2:BUILDING C
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 1:887 CONGRESS ST
Practice Address - Street 2:SUITE 200
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-3166
Practice Address - Country:US
Practice Address - Phone:207-771-5549
Practice Address - Fax:207-771-7834
Is Sole Proprietor?:No
Enumeration Date:2007-07-12
Last Update Date:2012-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMD18808207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH32000563Medicaid
NH32000563Medicaid