Provider Demographics
NPI:1952520694
Name:ARREDONDO, NICOLAS FLANNERY (MD)
Entity Type:Individual
Prefix:
First Name:NICOLAS
Middle Name:FLANNERY
Last Name:ARREDONDO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:195 FORE RIVER PKWY STE 440
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04102-2788
Mailing Address - Country:US
Mailing Address - Phone:072-553-6054
Mailing Address - Fax:207-553-6076
Practice Address - Street 1:195 FORE RIVER PKWY STE 440
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-2788
Practice Address - Country:US
Practice Address - Phone:207-553-6054
Practice Address - Fax:207-553-6076
Is Sole Proprietor?:No
Enumeration Date:2007-04-24
Last Update Date:2023-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMD21958207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003135431AMedicaid
GA003135431AMedicaid
GA6384360001Medicare NSC
GA202I142309Medicare Oscar/Certification