Healthcare Provider Details

I. General information

NPI: 1487182580
Provider Name (Legal Business Name): RETINA & UVEITIS CONSULTANTS OF MAINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/01/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

336 MOUNT HOPE AVE STE 1
BANGOR ME
04401-4236
US

IV. Provider business mailing address

336 MOUNT HOPE AVE STE 1
BANGOR ME
04401-4236
US

V. Phone/Fax

Practice location:
  • Phone: 207-573-1509
  • Fax: 207-573-1570
Mailing address:
  • Phone: 207-573-1509
  • Fax: 207-573-1570

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207WX0107X
TaxonomyRetina Specialist (Ophthalmology) Physician
License NumberMD21285
License Number StateME
# 2
Primary TaxonomyN
Taxonomy Code207WX0108X
TaxonomyUveitis and Ocular Inflammatory Disease (Ophthalmology) Physician
License NumberMD21285
License Number StateME

VIII. Authorized Official

Name: ANTHONY S. EKONG
Title or Position: SOLE OWNER
Credential: MD
Phone: 207-573-1509