Provider Demographics
NPI:1831171206
Name:DUBOIS, JOHN A (OD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:A
Last Name:DUBOIS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 18
Mailing Address - Street 2:
Mailing Address - City:CORNISH
Mailing Address - State:ME
Mailing Address - Zip Code:04020-0018
Mailing Address - Country:US
Mailing Address - Phone:207-625-3700
Mailing Address - Fax:207-625-3277
Practice Address - Street 1:91 MAPLE ST
Practice Address - Street 2:
Practice Address - City:CORNISH
Practice Address - State:ME
Practice Address - Zip Code:04020-3101
Practice Address - Country:US
Practice Address - Phone:207-625-3700
Practice Address - Fax:207-625-3277
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-18
Last Update Date:2016-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME836TA152W00000X
NH0698152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME14373851OtherAETNA
ME93222397OtherCIGNA
ME100431OtherANTHEM BCBS
ME93222397OtherCIGNA
U79021Medicare UPIN
ME100431OtherANTHEM BCBS