Provider Demographics
NPI:1538120043
Name:BOUMAN, PETER H (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:H
Last Name:BOUMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:70 LINCOLN ST
Mailing Address - Street 2:MILL 6
Mailing Address - City:LEWISTON
Mailing Address - State:ME
Mailing Address - Zip Code:04240-7792
Mailing Address - Country:US
Mailing Address - Phone:207-795-7540
Mailing Address - Fax:207-795-7528
Practice Address - Street 1:70 LINCOLN ST
Practice Address - Street 2:MILL 6
Practice Address - City:LEWISTON
Practice Address - State:ME
Practice Address - Zip Code:04240-7792
Practice Address - Country:US
Practice Address - Phone:207-795-7540
Practice Address - Fax:207-795-7528
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-01
Last Update Date:2007-10-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ME016653207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEI48259Medicare UPIN
MEME1776Medicare ID - Type Unspecified