Provider Demographics
NPI:1699844365
Name:HATZENBUEHLER, JOHN R (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:R
Last Name:HATZENBUEHLER
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 1:100 GANNETT DRIVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106
Mailing Address - Country:US
Mailing Address - Phone:207-828-0361
Mailing Address - Fax:207-874-1483
Practice Address - Street 1:100 FODEN RD, EAST
Practice Address - Street 2:SUITE 200
Practice Address - City:SOUTH PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106
Practice Address - Country:US
Practice Address - Phone:207-523-8500
Practice Address - Fax:207-523-8591
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2015-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMD17466207Q00000X, 207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30207627Medicaid
ME432651599Medicaid
ME000629707Medicare PIN
MEP01212393Medicare PIN
ME0629702Medicare PIN
ME000629708Medicare PIN
ME432651599Medicaid
NH30207627Medicaid
MEE400221839Medicare PIN
ME000629706Medicare PIN