Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 204D00000X | Neuromusculoskeletal Medicine (NMM) | ME 1773 | ME |
NPI | 1063418945 |
---|---|
Provider Name | Dr. Charles Gerard Landry |
First Address | Auburn, ME 04212-0338 |
Second Address | Auburn, ME 04210-3903 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 24/06/2005 |
Last Update Date | 15/03/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
022791 | ANTHEM BCBS (01) | ME |
3461045 | AETNA (01) | |
408470099 | (05) | ME |
I03750 | (02) |