Provider Demographics
NPI:1629097852
Name:FEOLI, ENRIQUE A (MD)
Entity Type:Individual
Prefix:
First Name:ENRIQUE
Middle Name:A
Last Name:FEOLI
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 1:498 ESSEX ST
Mailing Address - Street 2:SUITE 105
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-3990
Mailing Address - Country:US
Mailing Address - Phone:207-947-0558
Mailing Address - Fax:207-947-0344
Practice Address - Street 1:498 ESSEX ST
Practice Address - Street 2:SUITE 105
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-3990
Practice Address - Country:US
Practice Address - Phone:207-947-0558
Practice Address - Fax:207-947-0344
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2010-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME0161112084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME305470099Medicaid
ME3261081OtherCIGNA
ME7212513OtherAETNA
ME060521OtherANTHEM BLUE SHIELD
MEH89587Medicare UPIN
MEME0045Medicare ID - Type Unspecified
MEME004501Medicare PIN