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General NPI Number Information
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NPI Number | 1548366958
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Entity Type | Organization
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Legal Business Name | MID STATE EYE ASSOCIATES
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Dates
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Enumeration Date | 09/15/2006
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Last Update Date | 12/19/2007
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Provider Practice Location Address
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Address Line | 840 KENNEDY MEMORIAL DRIVE SUITE 2
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City | OAKLAND
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State | ME
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Zip | 04963
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Country | US
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Telephone | 207-465-9500
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Fax | 207-465-9500
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Provider Business Mailing Address
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Address Line | 840 KENNEDY MEMORIAL DRIVE SUITE 2
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City | OAKLAND
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State | ME
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Zip | 04963
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Country | US
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Telephone | 207-465-9500
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Fax | 207-465-9500
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Authorized Official
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Title or Position | CEO
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Name | MARK STEPHEN VARNUM
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Credential | OD
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Telephone | 207-465-9500
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | OPT747
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License Number State | ME
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