Healthcare Provider Details

I. General information

NPI: 1316259435
Provider Name (Legal Business Name): IAN MUKAND-CERRO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2010
Last Update Date: 11/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

417 STATE ST STE 439
BANGOR ME
04401-6635
US

IV. Provider business mailing address

417 STATE ST STE 439
BANGOR ME
04401-6635
US

V. Phone/Fax

Practice location:
  • Phone: 207-941-8200
  • Fax: 207-990-4848
Mailing address:
  • Phone: 207-941-8200
  • Fax: 207-990-4848

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number258041
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number28520
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: