Provider Demographics
NPI:1811121684
Name:TRYDESTAM, CECILIA K (MD)
Entity type:Individual
Prefix:
First Name:CECILIA
Middle Name:K
Last Name:TRYDESTAM
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:770 ROOSEVELT TRAIL
Mailing Address - Street 2:STE 8 #1015
Mailing Address - City:N WINDHAM
Mailing Address - State:ME
Mailing Address - Zip Code:04062
Mailing Address - Country:US
Mailing Address - Phone:207-717-9550
Mailing Address - Fax:
Practice Address - Street 1:93 CAMPUS AVE I2 WING
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ME
Practice Address - Zip Code:04240
Practice Address - Country:US
Practice Address - Phone:207-777-8650
Practice Address - Fax:207-777-8641
Is Sole Proprietor?:No
Enumeration Date:2009-05-08
Last Update Date:2025-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60458584208600000X
MEMD24297208600000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1811121684Medicaid
WAP01625698OtherRR MEDICARE WVH
WAP01625698OtherRR MEDICARE WVH