Provider Demographics
NPI:1720068703
Name:GAYLORD, SUSAN
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:GAYLORD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:287 MAIN ST
Mailing Address - Street 2:STE 201
Mailing Address - City:LEWISTON
Mailing Address - State:ME
Mailing Address - Zip Code:04240-7054
Mailing Address - Country:US
Mailing Address - Phone:207-795-7180
Mailing Address - Fax:207-795-7179
Practice Address - Street 1:287 MAIN ST
Practice Address - Street 2:STE 201
Practice Address - City:LEWISTON
Practice Address - State:ME
Practice Address - Zip Code:04240-7054
Practice Address - Country:US
Practice Address - Phone:207-795-7180
Practice Address - Fax:207-795-7179
Is Sole Proprietor?:No
Enumeration Date:2006-01-18
Last Update Date:2010-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME12540207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEB86450Medicare UPIN
MENX2543Medicare PIN
MEMM1162Medicare ID - Type Unspecified