Provider Demographics
NPI:1568459667
Name:PUERTO, OTONIEL DAVID (MD)
Entity Type:Individual
Prefix:DR
First Name:OTONIEL
Middle Name:DAVID
Last Name:PUERTO
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:C/O ST MARYS HEALTH SYSTEM - PROVIDER ENROLLMENT
Mailing Address - Street 2:PO BOX 7291
Mailing Address - City:LEWISTON
Mailing Address - State:ME
Mailing Address - Zip Code:04243-7291
Mailing Address - Country:US
Mailing Address - Phone:207-777-8941
Mailing Address - Fax:207-777-8800
Practice Address - Street 1:360 BROADWAY
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401
Practice Address - Country:US
Practice Address - Phone:207-907-1430
Practice Address - Fax:207-907-3508
Is Sole Proprietor?:No
Enumeration Date:2005-10-04
Last Update Date:2022-02-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KY34465207L00000X, 207LP2900X
MEMD22859207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYPENDINGMedicaid
KYPENDINGMedicaid
G99985Medicare UPIN