Provider Demographics
NPI:1689699852
Name:PELLETIER, PAUL MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:MICHAEL
Last Name:PELLETIER
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 1:10 CARTER ST.
Mailing Address - Street 2:PO BOX 309
Mailing Address - City:EAGLE LAKE
Mailing Address - State:ME
Mailing Address - Zip Code:04739-0309
Mailing Address - Country:US
Mailing Address - Phone:207-444-5973
Mailing Address - Fax:207-444-5520
Practice Address - Street 1:10 CARTER ST.
Practice Address - Street 2:
Practice Address - City:EAGLE LAKE
Practice Address - State:ME
Practice Address - Zip Code:04739-0309
Practice Address - Country:US
Practice Address - Phone:207-444-5973
Practice Address - Fax:207-444-5520
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2008-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME012992207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME265330099Medicaid
ME265330099Medicaid
ME201802Medicare Oscar/Certification
MEMM2976Medicare PIN