Provider Demographics
NPI:1780602755
Name:BONIFACE, ANNE M (MD)
Entity type:Individual
Prefix:
First Name:ANNE
Middle Name:M
Last Name:BONIFACE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:43 WHITING HILL RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:BREWER
Mailing Address - State:ME
Mailing Address - Zip Code:04412-1005
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:133 CORPORATE DR
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-4312
Practice Address - Country:US
Practice Address - Phone:207-275-4201
Practice Address - Fax:207-275-4262
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2016-11-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MEMD154232080P0205X
MEME015423208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Yes2080P0205XAllopathic & Osteopathic PhysiciansPediatricsPediatric Endocrinology
Provider Identifiers
StateIdentifier IDID TypeIssuer
F31773Medicare UPIN