Provider Demographics
NPI:1811057458
Name:FLYNN, JOSEPH WAYNE (MD)
Entity type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:WAYNE
Last Name:FLYNN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 BATES STREET
Mailing Address - Street 2:P.O. BOX 1288
Mailing Address - City:LEWISTON
Mailing Address - State:ME
Mailing Address - Zip Code:04243-1288
Mailing Address - Country:US
Mailing Address - Phone:207-784-4539
Mailing Address - Fax:207-784-2868
Practice Address - Street 1:12 BATES STREET
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ME
Practice Address - Zip Code:04240
Practice Address - Country:US
Practice Address - Phone:207-784-4539
Practice Address - Fax:207-784-2868
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2008-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME011924174400000X
NM78-160174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME01-0533065OtherTIN
ME01-0372457OtherPREVIOUS TIN
MED03550Medicare UPIN