Healthcare Provider Details

I. General information

NPI: 1356312599
Provider Name (Legal Business Name): JOHN R O'MEARA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/27/2006
Last Update Date: 10/01/2020
Certification Date: 10/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

331 VERANDA ST
PORTLAND ME
04103-5545
US

IV. Provider business mailing address

PO BOX 9746
PORTLAND ME
04104-5040
US

V. Phone/Fax

Practice location:
  • Phone: 207-878-2402
  • Fax: 207-828-2425
Mailing address:
  • Phone: 207-799-3888
  • Fax: 207-828-7850

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number013095
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: