Provider Demographics
NPI:1518315142
Name:TIVNAN, JOHN (DO)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:TIVNAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:1365 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-2401
Mailing Address - Country:US
Mailing Address - Phone:207-942-6226
Mailing Address - Fax:207-992-2756
Practice Address - Street 1:1365 BROADWAY
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-2401
Practice Address - Country:US
Practice Address - Phone:207-942-6226
Practice Address - Fax:207-992-2756
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-24
Last Update Date:2023-01-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MEDO3257207LP2900X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty