Provider Demographics
NPI:1770887002
Name:JOHN C. HERSEY OD, PC
Entity type:Organization
Organization Name:JOHN C. HERSEY OD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:C
Authorized Official - Last Name:HERSEY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:207-233-5555
Mailing Address - Street 1:PO BOX 421
Mailing Address - Street 2:
Mailing Address - City:WINTERPORT
Mailing Address - State:ME
Mailing Address - Zip Code:04496-0421
Mailing Address - Country:US
Mailing Address - Phone:207-233-5555
Mailing Address - Fax:
Practice Address - Street 1:663 STILLWATER AVE
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-3680
Practice Address - Country:US
Practice Address - Phone:207-262-7192
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-30
Last Update Date:2011-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEOPT856152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEMM9051Medicare PIN
MEU86945Medicare UPIN