Provider Demographics
NPI:1508925363
Name:GOLDTHWAIT, PHILIP N (OD)
Entity Type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:N
Last Name:GOLDTHWAIT
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:663 STILLWATER AVE
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-3642
Mailing Address - Country:US
Mailing Address - Phone:207-945-4452
Mailing Address - Fax:207-945-9450
Practice Address - Street 1:663 STILLWATER AVE
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-3642
Practice Address - Country:US
Practice Address - Phone:207-945-4452
Practice Address - Fax:207-945-9450
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-07
Last Update Date:2012-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEOPT751152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist