Provider Demographics
NPI:1104919901
Name:HAEBERLEIN, ROBERT WYNNE JR (MD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:WYNNE
Last Name:HAEBERLEIN
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 MOUNT HOPE AVENUE SUITE 601
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-5600
Mailing Address - Country:US
Mailing Address - Phone:207-942-4653
Mailing Address - Fax:207-990-4795
Practice Address - Street 1:700 MOUNT HOPE AVENUE SUITE 601
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-5600
Practice Address - Country:US
Practice Address - Phone:207-942-4653
Practice Address - Fax:207-990-4795
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2009-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME009794207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME110090000Medicaid
MEPINMedicare PIN
B86769Medicare UPIN
054772Medicare PIN