Provider Demographics
NPI:1356578272
Name:VIDELOCK, ELIZABETH JANE (MD)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:JANE
Last Name:VIDELOCK
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 1:10 WAYMAN LN
Mailing Address - Street 2:MDI HOSPITAL
Mailing Address - City:BAR HARBOR
Mailing Address - State:ME
Mailing Address - Zip Code:04609-1625
Mailing Address - Country:US
Mailing Address - Phone:207-288-5082
Mailing Address - Fax:207-288-8600
Practice Address - Street 1:10 WAYMAN LN
Practice Address - Street 2:MDI HOSPITAL
Practice Address - City:BAR HARBOR
Practice Address - State:ME
Practice Address - Zip Code:04609-1625
Practice Address - Country:US
Practice Address - Phone:207-288-5082
Practice Address - Fax:207-288-8600
Is Sole Proprietor?:No
Enumeration Date:2009-06-18
Last Update Date:2013-03-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
METD 121060207R00000X
MA250421207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME2981101Medicare PIN