Provider Demographics
NPI:1962507236
Name:MARTIN, KRISTEN S (DO)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:S
Last Name:MARTIN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:KRISTEN
Other - Middle Name:L
Other - Last Name:SOUWEINE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:PO BOX 1599
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04402-1599
Mailing Address - Country:US
Mailing Address - Phone:207-945-5247
Mailing Address - Fax:207-947-0435
Practice Address - Street 1:6 TELCOM DR
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-3072
Practice Address - Country:US
Practice Address - Phone:207-947-0147
Practice Address - Fax:207-990-3365
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2021-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEDO1959208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME432302699Medicaid
MEMM9086Medicare PIN