Provider Demographics
NPI:1811076532
Name:LOUPIN, DEREK
Entity type:Individual
Prefix:
First Name:DEREK
Middle Name:
Last Name:LOUPIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 EARLE AVE # 2
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-3462
Mailing Address - Country:US
Mailing Address - Phone:207-947-4211
Mailing Address - Fax:
Practice Address - Street 1:12 STILLWATER AVE
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-3984
Practice Address - Country:US
Practice Address - Phone:207-945-2946
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEPT2667OtherLICENSE#