Healthcare Provider Details

I. General information

NPI: 1215917885
Provider Name (Legal Business Name): TIMOTHY DEWITT CARNES JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/19/2006
Last Update Date: 04/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17 BISHOP ST
PORTLAND ME
04103-2659
US

IV. Provider business mailing address

17 BISHOP ST
PORTLAND ME
04103-2659
US

V. Phone/Fax

Practice location:
  • Phone: 207-835-0488
  • Fax: 207-835-0359
Mailing address:
  • Phone: 207-835-0488
  • Fax: 207-835-0359

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RA0000X
TaxonomyAdolescent Medicine (Internal Medicine) Physician
License Number16503
License Number StateME
# 2
Primary TaxonomyY
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License Number16503
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: