Provider Demographics
NPI:1578663365
Name:ABBOTT, AMY M (OD)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:M
Last Name:ABBOTT
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:272 COTTAGE ST
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:ME
Mailing Address - Zip Code:04073-1815
Mailing Address - Country:US
Mailing Address - Phone:207-324-8888
Mailing Address - Fax:207-490-1716
Practice Address - Street 1:510 MAINEMALL RD.
Practice Address - Street 2:
Practice Address - City:SOUTH PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106
Practice Address - Country:US
Practice Address - Phone:207-775-2030
Practice Address - Fax:207-775-0755
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEOPT864152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME098598OtherANTHEM
ME0002921OtherMEDICARE GROUP #
ME1649464983OtherGROUP NPI #
ME1649464983OtherGROUP NPI #
MEME186801Medicare PIN