Provider Demographics
NPI:1194795799
Name:KANDUTSCH, MARK A (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:KANDUTSCH
Suffix:
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 1:10 WAYMAN LN
Mailing Address - Street 2:
Mailing Address - City:BAR HARBOR
Mailing Address - State:ME
Mailing Address - Zip Code:04609-1625
Mailing Address - Country:US
Mailing Address - Phone:207-288-5081
Mailing Address - Fax:207-288-8449
Practice Address - Street 1:322 MAIN ST
Practice Address - Street 2:
Practice Address - City:BAR HARBOR
Practice Address - State:ME
Practice Address - Zip Code:04609-1648
Practice Address - Country:US
Practice Address - Phone:207-288-5081
Practice Address - Fax:207-288-8449
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2017-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMD10687207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME101990099Medicaid
MEMD10687OtherMAINE LICENSE
MEB86514Medicare UPIN
ME01506601Medicare PIN