Provider Demographics
NPI:1366401291
Name:O'BRIEN, TODD D (DPM)
Entity type:Individual
Prefix:
First Name:TODD
Middle Name:D
Last Name:O'BRIEN
Suffix:
Gender:M
Credentials:DPM
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 1599
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04402-1599
Mailing Address - Country:US
Mailing Address - Phone:207-404-8200
Mailing Address - Fax:207-947-0435
Practice Address - Street 1:242 BRUNSWICK ST
Practice Address - Street 2:
Practice Address - City:OLD TOWN
Practice Address - State:ME
Practice Address - Zip Code:04468-1613
Practice Address - Country:US
Practice Address - Phone:207-827-6128
Practice Address - Fax:207-827-6605
Is Sole Proprietor?:No
Enumeration Date:2006-03-20
Last Update Date:2021-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPOD1016213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME030284OtherANTHEM
ME480034965OtherMEDICARE PTAN
ME154750099Medicaid
ME201839OtherNGS
ME480034965OtherMEDICARE PTAN
MEMM9711Medicare Oscar/Certification
ME4683520001Medicare NSC
ME030284OtherANTHEM