Provider Demographics
NPI:1336207901
Name:PUCKHABER, DEBORAH J (MD)
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:J
Last Name:PUCKHABER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:300 MAIN ST
Mailing Address - Street 2:CENTRAL MAINE MEDICAL CENTER
Mailing Address - City:LEWISTON
Mailing Address - State:ME
Mailing Address - Zip Code:04240-7027
Mailing Address - Country:US
Mailing Address - Phone:207-795-5970
Mailing Address - Fax:207-795-7193
Practice Address - Street 1:300 MAIN ST
Practice Address - Street 2:CENTRAL MAINE MEDICAL CENTER
Practice Address - City:LEWISTON
Practice Address - State:ME
Practice Address - Zip Code:04240-7027
Practice Address - Country:US
Practice Address - Phone:207-795-7575
Practice Address - Fax:207-795-7193
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2017-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY173763207R00000X
MEMD20227207R00000X
IN01069603A207R00000X
METD141074208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201045220Medicaid
NH30204794Medicaid
IN000000745189OtherANTHEM PROVIDER NUMBER
NH020475714OtherTAX ID
IN201045220Medicaid
NYJ400019154Medicare PIN
INP01028455Medicare PIN
NH30204794Medicaid
NHRE8044Medicare PIN