Healthcare Provider Details

I. General information

NPI: 1780602755
Provider Name (Legal Business Name): ANNE M BONIFACE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 11/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

133 CORPORATE DR
BANGOR ME
04401-4312
US

IV. Provider business mailing address

43 WHITING HILL RD SUITE 300
BREWER ME
04412-1005
US

V. Phone/Fax

Practice location:
  • Phone: 207-275-4201
  • Fax: 207-275-4262
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0205X
TaxonomyPediatric Endocrinology Physician
License NumberMD15423
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: