Healthcare Provider Details

I. General information

NPI: 1548293772
Provider Name (Legal Business Name): GEORGE W STOCKWELL D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2006
Last Update Date: 02/17/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

409 ROOSEVELT TRL
WINDHAM ME
04062-4821
US

IV. Provider business mailing address

144 STATE ST
PORTLAND ME
04101-3776
US

V. Phone/Fax

Practice location:
  • Phone: 207-893-0290
  • Fax: 207-400-8633
Mailing address:
  • Phone: 207-879-3000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number1354
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: