Provider Demographics
NPI:1104956143
Name:GAUVREAU, DOUGLAS KENT (OD)
Entity type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:KENT
Last Name:GAUVREAU
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:151 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WESTBROOK
Mailing Address - State:ME
Mailing Address - Zip Code:04092-4808
Mailing Address - Country:US
Mailing Address - Phone:207-854-1801
Mailing Address - Fax:207-854-0260
Practice Address - Street 1:151 MAIN ST
Practice Address - Street 2:
Practice Address - City:WESTBROOK
Practice Address - State:ME
Practice Address - Zip Code:04092-4808
Practice Address - Country:US
Practice Address - Phone:207-854-1801
Practice Address - Fax:207-854-0260
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2009-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEOPT554152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME0468580001OtherMEDICARE DMEPOS
ME410032606OtherRAILROAD MEDICARE
ME107830099Medicaid
ME000378OtherBC & BS
MET31693Medicare UPIN
ME70378901Medicare PIN