Provider Demographics
NPI:1609812551
Name:STOCKWELL, IRA W (DO)
Entity Type:Individual
Prefix:
First Name:IRA
Middle Name:W
Last Name:STOCKWELL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Mailing Address - Street 1:2 CHABOT ST
Mailing Address - Street 2:STE 2
Mailing Address - City:WESTBROOK
Mailing Address - State:ME
Mailing Address - Zip Code:04092-4815
Mailing Address - Country:US
Mailing Address - Phone:207-857-9311
Mailing Address - Fax:207-857-9324
Practice Address - Street 1:344 CUMBERLAND ST
Practice Address - Street 2:
Practice Address - City:WESTBROOK
Practice Address - State:ME
Practice Address - Zip Code:04092-2408
Practice Address - Country:US
Practice Address - Phone:207-854-8200
Practice Address - Fax:207-854-8200
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-21
Last Update Date:2019-06-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ME847208D00000X
MEDO847207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME199930099Medicaid
MED98442Medicare UPIN