Basic Information
| Provider Information | |||||||||
| NPI: | 1366401291 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | O'BRIEN | ||||||||
| FirstName: | TODD | ||||||||
| MiddleName: | D | ||||||||
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| NameSuffix: | |||||||||
| Credential: | DPM | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1599 | ||||||||
| Address2: | |||||||||
| City: | BANGOR | ||||||||
| State: | ME | ||||||||
| PostalCode: | 044021599 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2074048200 | ||||||||
| FaxNumber: | 2079470435 | ||||||||
| Practice Location | |||||||||
| Address1: | 242 BRUNSWICK ST | ||||||||
| Address2: | |||||||||
| City: | OLD TOWN | ||||||||
| State: | ME | ||||||||
| PostalCode: | 044681613 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2078276128 | ||||||||
| FaxNumber: | 2078276605 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2006 | ||||||||
| LastUpdateDate: | 05/05/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X | POD1016 | ME | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
ID Information
| ID | Type | State | Issuer | Description | 030284 | 01 | ME | ANTHEM | OTHER | 480034965 | 01 | ME | MEDICARE PTAN | OTHER | 154750099 | 05 | ME | MEDICAID | 201839 | 01 | ME | NGS | OTHER |