Provider Demographics
NPI:1477521482
Name:MAXWELL, BRYAN DOUGLAS (DO)
Entity Type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:DOUGLAS
Last Name:MAXWELL
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 1:9 HEALTHCARE DR
Mailing Address - Street 2:
Mailing Address - City:BIDDEFORD
Mailing Address - State:ME
Mailing Address - Zip Code:04005-9449
Mailing Address - Country:US
Mailing Address - Phone:207-282-4270
Mailing Address - Fax:207-294-8332
Practice Address - Street 1:9 HEALTHCARE DR
Practice Address - Street 2:
Practice Address - City:BIDDEFORD
Practice Address - State:ME
Practice Address - Zip Code:04005-9449
Practice Address - Country:US
Practice Address - Phone:207-282-4270
Practice Address - Fax:207-294-8332
Is Sole Proprietor?:No
Enumeration Date:2006-03-08
Last Update Date:2024-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEDO3418207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010092761Medicaid
VAI12126Medicare UPIN
VA005165L74Medicare ID - Type Unspecified