Provider Demographics
NPI:1720053606
Name:DEGEN, GARY P (DPM)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:P
Last Name:DEGEN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 99
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:ME
Mailing Address - Zip Code:04457-0099
Mailing Address - Country:US
Mailing Address - Phone:207-794-6700
Mailing Address - Fax:
Practice Address - Street 1:175 W BROADWAY
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:ME
Practice Address - Zip Code:04457-4000
Practice Address - Country:US
Practice Address - Phone:207-794-6700
Practice Address - Fax:207-794-6777
Is Sole Proprietor?:No
Enumeration Date:2006-02-22
Last Update Date:2014-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY00320213ES0103X
MEPOD1023213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYCH0142OtherRAILROAD GROUP
KYCH0142OtherRAILROAD GROUP
KY0393606Medicare PIN