Provider Demographics
NPI:1700831278
Name:TOOTHAKER, JOHN LLEWELLYN (DPM)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:LLEWELLYN
Last Name:TOOTHAKER
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:168 GROVE ST
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:ME
Mailing Address - Zip Code:04953-3347
Mailing Address - Country:US
Mailing Address - Phone:207-368-5415
Mailing Address - Fax:207-368-5415
Practice Address - Street 1:168 GROVE ST
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:ME
Practice Address - Zip Code:04953-3347
Practice Address - Country:US
Practice Address - Phone:207-368-5415
Practice Address - Fax:207-368-5415
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPOD141213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME200340100Medicaid
MET31666Medicare UPIN
ME602388Medicare ID - Type UnspecifiedMEDICARE PROVIDER ID
MEME0333Medicare ID - Type UnspecifiedMEDICARE GROUP ID