Provider Demographics
NPI:1457456733
Name:MAMULA, MEGHAN R (DO)
Entity Type:Individual
Prefix:
First Name:MEGHAN
Middle Name:R
Last Name:MAMULA
Suffix:
Gender:F
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:PO BOX 1599
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04402-1599
Mailing Address - Country:US
Mailing Address - Phone:207-945-5247
Mailing Address - Fax:207-947-0435
Practice Address - Street 1:735 WILSON ST
Practice Address - Street 2:
Practice Address - City:BREWER
Practice Address - State:ME
Practice Address - Zip Code:04412-1000
Practice Address - Country:US
Practice Address - Phone:207-992-2601
Practice Address - Fax:207-989-2280
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2021-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEDO1691207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME267430099Medicaid
MM8563Medicare PIN
H28952Medicare UPIN
MEH28952Medicare PIN