Provider Demographics
NPI:1740251172
Name:CALEBAUGH, MARY JO MILES (MD)
Entity type:Individual
Prefix:DR
First Name:MARY JO
Middle Name:MILES
Last Name:CALEBAUGH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:11 BACK RD
Mailing Address - Street 2:PO BOX 351
Mailing Address - City:PLEASANT POINT
Mailing Address - State:ME
Mailing Address - Zip Code:04667-4119
Mailing Address - Country:US
Mailing Address - Phone:207-853-0644
Mailing Address - Fax:207-853-6230
Practice Address - Street 1:11 BACK RD
Practice Address - Street 2:
Practice Address - City:PLEASANT POINT
Practice Address - State:ME
Practice Address - Zip Code:04667-4119
Practice Address - Country:US
Practice Address - Phone:207-853-0644
Practice Address - Fax:207-853-6230
Is Sole Proprietor?:No
Enumeration Date:2006-02-01
Last Update Date:2012-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY237412207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02711668Medicaid
06061121OtherECFMG