Healthcare Provider Details

I. General information

NPI: 1649714742
Provider Name (Legal Business Name): FULL CIRCLE DIRECT PRIMARY CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/07/2016
Last Update Date: 12/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

68 CHAPMAN ST
DAMARISCOTTA ME
04543-4614
US

IV. Provider business mailing address

68 CHAPMAN ST
DAMARISCOTTA ME
04543-4614
US

V. Phone/Fax

Practice location:
  • Phone: 207-563-6616
  • Fax: 207-563-6625
Mailing address:
  • Phone: 207-563-6616
  • Fax: 207-563-6625

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD13738
License Number StateME

VIII. Authorized Official

Name: DR. MINDA JANE GOLD
Title or Position: PRESIDENT
Credential: MD
Phone: 207-563-6616