Provider Demographics
NPI:1477571362
Name:PETZEL, JANIS BACON (MD)
Entity Type:Individual
Prefix:DR
First Name:JANIS
Middle Name:BACON
Last Name:PETZEL
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 1:165 SECOND ST
Mailing Address - Street 2:
Mailing Address - City:HALLOWELL
Mailing Address - State:ME
Mailing Address - Zip Code:04347-1130
Mailing Address - Country:US
Mailing Address - Phone:207-242-4007
Mailing Address - Fax:
Practice Address - Street 1:116 SECOND ST
Practice Address - Street 2:SUITE 1
Practice Address - City:HALLOWELL
Practice Address - State:ME
Practice Address - Zip Code:04347-1331
Practice Address - Country:US
Practice Address - Phone:207-242-4007
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2016-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME0156532084P0800X, 2084P0805X
WAMD606507232084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEMM9050Medicare UPIN