Provider Demographics
NPI:1851550677
Name:PELLETIER, JOAN D (DO)
Entity Type:Individual
Prefix:
First Name:JOAN
Middle Name:D
Last Name:PELLETIER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:JOAN
Other - Middle Name:E
Other - Last Name:DUPONT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:9 HEALTHCARE DRIVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:BIDDEFORD
Mailing Address - State:ME
Mailing Address - Zip Code:04005-9450
Mailing Address - Country:US
Mailing Address - Phone:207-282-7531
Mailing Address - Fax:207-286-3787
Practice Address - Street 1:9 HEALTHCARE DRIVE
Practice Address - Street 2:SUITE 208
Practice Address - City:BIDDEFORD
Practice Address - State:ME
Practice Address - Zip Code:04005-9450
Practice Address - Country:US
Practice Address - Phone:207-282-7531
Practice Address - Fax:207-286-3787
Is Sole Proprietor?:No
Enumeration Date:2008-06-06
Last Update Date:2011-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME2218208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME1851550677Medicaid