Healthcare Provider Details

I. General information

NPI: 1104956143
Provider Name (Legal Business Name): DOUGLAS KENT GAUVREAU O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2007
Last Update Date: 07/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

151 MAIN ST
WESTBROOK ME
04092-4808
US

IV. Provider business mailing address

151 MAIN ST
WESTBROOK ME
04092-4808
US

V. Phone/Fax

Practice location:
  • Phone: 207-854-1801
  • Fax: 207-854-0260
Mailing address:
  • Phone: 207-854-1801
  • Fax: 207-854-0260

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License NumberOPT554
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: