Provider Demographics
NPI:1851301022
Name:GONYEA, MICHAEL HAROLD (OD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:HAROLD
Last Name:GONYEA
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 1:82 WATER ST
Mailing Address - Street 2:
Mailing Address - City:ELLSWORTH
Mailing Address - State:ME
Mailing Address - Zip Code:04605-2006
Mailing Address - Country:US
Mailing Address - Phone:207-667-8615
Mailing Address - Fax:207-667-4212
Practice Address - Street 1:82 WATER ST
Practice Address - Street 2:
Practice Address - City:ELLSWORTH
Practice Address - State:ME
Practice Address - Zip Code:04605-2006
Practice Address - Country:US
Practice Address - Phone:207-667-8615
Practice Address - Fax:207-667-4212
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEOPT708152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME010999OtherBLUE CROSS
ME522108187534OtherCHAMPUS
ME410026218OtherMEDICARE RAILROAD
ME253160099Medicaid
ME1190660001OtherDMERC
ME010999OtherBLUE CROSS
ME1190660001OtherDMERC