Provider Demographics
NPI:1922184613
Name:IKOSSI, MARIA G (MD)
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:G
Last Name:IKOSSI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARLA
Other - Middle Name:G
Other - Last Name:IKOSSI OCONNOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 7291
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ME
Mailing Address - Zip Code:04243-7291
Mailing Address - Country:US
Mailing Address - Phone:207-777-8950
Mailing Address - Fax:207-777-8800
Practice Address - Street 1:99 CAMPUS AVE STE 401
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ME
Practice Address - Zip Code:04240
Practice Address - Country:US
Practice Address - Phone:207-777-8650
Practice Address - Fax:207-777-8641
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2020-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMD12822208G00000X, 208600000X
CAC52151208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME126580000Medicaid
MEMM245503Medicare Oscar/Certification
A58468Medicare UPIN
IKMM2455Medicare ID - Type UnspecifiedINDIVIDUAL