Provider Demographics
NPI:1558498915
Name:LACKOFF, ANDREW (MD)
Entity Type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:
Last Name:LACKOFF
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 GLEN COVE DR
Mailing Address - Street 2:
Mailing Address - City:ROCKPORT
Mailing Address - State:ME
Mailing Address - Zip Code:04856-4240
Mailing Address - Country:US
Mailing Address - Phone:207-596-8000
Mailing Address - Fax:207-593-5302
Practice Address - Street 1:6 GLEN COVE DR
Practice Address - Street 2:
Practice Address - City:ROCKPORT
Practice Address - State:ME
Practice Address - Zip Code:04856-4240
Practice Address - Country:US
Practice Address - Phone:207-596-8000
Practice Address - Fax:207-593-5302
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2013-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME0117709207Q00000X
MEMD11709208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
B86415Medicare UPIN