Provider Demographics
NPI:1649464983
Name:ROGER R GAGNON
Entity type:Organization
Organization Name:ROGER R GAGNON
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:R
Authorized Official - Last Name:GAGNON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:207-775-2030
Mailing Address - Street 1:510 MAINE MALL
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-3238
Mailing Address - Country:US
Mailing Address - Phone:207-775-2030
Mailing Address - Fax:
Practice Address - Street 1:510 MAINE MALL
Practice Address - Street 2:
Practice Address - City:SOUTH PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106-3238
Practice Address - Country:US
Practice Address - Phone:207-775-2030
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-29
Last Update Date:2007-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME1124128913OtherINDIVIDUAL NPI NUMBER
ME014336OtherANTHEM
ME1124128913OtherINDIVIDUAL NPI NUMBER
MET87062Medicare UPIN