Healthcare Provider Details

I. General information

NPI: 1902802028
Provider Name (Legal Business Name): PETER S HEDSTROM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/23/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 LOWELL ST
PORTLAND ME
04102-2748
US

IV. Provider business mailing address

15 LOWELL ST
PORTLAND ME
04102-2748
US

V. Phone/Fax

Practice location:
  • Phone: 207-774-8277
  • Fax: 207-871-1415
Mailing address:
  • Phone: 207-774-8277
  • Fax: 207-871-1415

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number011295
License Number StateME
# 2
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number7030
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: