Healthcare Provider Details

I. General information

NPI: 1891149944
Provider Name (Legal Business Name): DOMANTAS MIKONIS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/14/2016
Last Update Date: 09/04/2026
Certification Date: 09/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2178 POST RD STE 205
WELLS ME
04090-4794
US

IV. Provider business mailing address

2178 POST RD STE 205
WELLS ME
04090-4794
US

V. Phone/Fax

Practice location:
  • Phone: 207-216-1342
  • Fax: 800-851-4724
Mailing address:
  • Phone: 207-216-1342
  • Fax: 800-851-4724

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberDO3094
License Number StateME
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number72934-21
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: