Healthcare Provider Details

I. General information

NPI: 1295787133
Provider Name (Legal Business Name): ALEXANDER BRAZALOVICH DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

813 MAIN ST MASSABESIC REGIONAL MEDICAL CENTER
WATERBORO ME
04087-3006
US

IV. Provider business mailing address

33 DOUGLAS AVE
SACO ME
04072-9732
US

V. Phone/Fax

Practice location:
  • Phone: 207-247-6131
  • Fax: 207-247-6675
Mailing address:
  • Phone: 207-283-2842
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number1364
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: