Provider Demographics
NPI:1457439663
Name:COBEAN, ROY A (MD)
Entity Type:Individual
Prefix:
First Name:ROY
Middle Name:A
Last Name:COBEAN
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 1:10 ANDOVER RD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04102-1954
Mailing Address - Country:US
Mailing Address - Phone:207-761-6642
Mailing Address - Fax:207-773-2603
Practice Address - Street 1:10 ANDOVER RD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-1954
Practice Address - Country:US
Practice Address - Phone:207-761-6642
Practice Address - Fax:207-773-2603
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2008-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME013447208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME303190099Medicaid
ME154600000Medicaid
ME154600000Medicaid
MEMM4578Medicare PIN
MEMM6750Medicare PIN