Provider Demographics
NPI:1063418945
Name:LANDRY, CHARLES GERARD (DO)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:GERARD
Last Name:LANDRY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 338
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:ME
Mailing Address - Zip Code:04212-0338
Mailing Address - Country:US
Mailing Address - Phone:207-241-0401
Mailing Address - Fax:
Practice Address - Street 1:871 COURT ST
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:ME
Practice Address - Zip Code:04210-3903
Practice Address - Country:US
Practice Address - Phone:207-241-0401
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-24
Last Update Date:2019-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEME 1773204D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME022791OtherANTHEM BCBS
3461045OtherAETNA
ME408470099Medicaid
I03750Medicare UPIN
ME0552Medicare ID - Type Unspecified