Provider Demographics
NPI:1700816352
Name:HERSEY, JOHN C (OD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:C
Last Name:HERSEY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 421
Mailing Address - Street 2:
Mailing Address - City:WINTERPORT
Mailing Address - State:ME
Mailing Address - Zip Code:04496-0421
Mailing Address - Country:US
Mailing Address - Phone:207-223-5555
Mailing Address - Fax:207-223-5555
Practice Address - Street 1:14 PARSONAGE ST
Practice Address - Street 2:
Practice Address - City:WINTERPORT
Practice Address - State:ME
Practice Address - Zip Code:04496
Practice Address - Country:US
Practice Address - Phone:207-223-5555
Practice Address - Fax:207-223-5555
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2011-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEOPT856152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEU86945Medicare UPIN
MEMM9051Medicare ID - Type Unspecified