Healthcare Provider Details

I. General information

NPI: 1710125596
Provider Name (Legal Business Name): KENNETH MAISAK DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/02/2009
Last Update Date: 09/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

68 MARGINAL WAY
PORTLAND ME
04101-2444
US

IV. Provider business mailing address

68 MARGINAL WAY
PORTLAND ME
04101-2444
US

V. Phone/Fax

Practice location:
  • Phone: 207-879-1339
  • Fax: 207-879-1092
Mailing address:
  • Phone: 207-879-1339
  • Fax: 207-879-1092

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberPOD1077
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: