Provider Demographics
NPI:1134178106
Name:MAXWELL, DOMINIC J (MD)
Entity type:Individual
Prefix:
First Name:DOMINIC
Middle Name:J
Last Name:MAXWELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 CANTERBURY LN
Mailing Address - Street 2:
Mailing Address - City:VINEYARD HAVEN
Mailing Address - State:MA
Mailing Address - Zip Code:02568-5658
Mailing Address - Country:US
Mailing Address - Phone:508-687-9592
Mailing Address - Fax:508-687-9567
Practice Address - Street 1:15 CHURCH ST
Practice Address - Street 2:
Practice Address - City:VINEYARD HAVEN
Practice Address - State:MA
Practice Address - Zip Code:02568
Practice Address - Country:US
Practice Address - Phone:508-687-9592
Practice Address - Fax:508-687-9567
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-08
Last Update Date:2011-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL000259832084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009933454Medicaid
AL051530946OtherBC BS OF AL
H21247Medicare UPIN
AL051556874Medicare ID - Type Unspecified