Provider Demographics
NPI:1124128913
Name:GAGNON, ROGER R (OD)
Entity type:Individual
Prefix:
First Name:ROGER
Middle Name:R
Last Name:GAGNON
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 1:510 MAINEMALL ROAD
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106
Mailing Address - Country:US
Mailing Address - Phone:207-775-2030
Mailing Address - Fax:207-775-0755
Practice Address - Street 1:510 MAINEMALL RD.
Practice Address - Street 2:
Practice Address - City:SOUTH PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106
Practice Address - Country:US
Practice Address - Phone:207-775-2030
Practice Address - Fax:207-775-0755
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-22
Last Update Date:2010-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEOPT740152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME121300099Medicaid
ME121300099Medicaid
MEMM2671Medicare PIN