Provider Demographics
NPI:1669456406
Name:MAMON, JOHN (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:MAMON
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:04856-4272
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6 GLEN COVE DR
Practice Address - Street 2:
Practice Address - City:ROCKPORT
Practice Address - State:ME
Practice Address - Zip Code:04856-4272
Practice Address - Country:US
Practice Address - Phone:207-662-4735
Practice Address - Fax:207-662-6388
Is Sole Proprietor?:No
Enumeration Date:2005-12-05
Last Update Date:2020-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360754572085R0202X
MEMD237522085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME1669456406Medicaid
IL036075457Medicaid
ILK15201Medicare ID - Type Unspecified