Provider Demographics
NPI:1699888958
Name:KETZLER, LECEA A (DO)
Entity type:Individual
Prefix:
First Name:LECEA
Middle Name:A
Last Name:KETZLER
Suffix:
Gender:F
Credentials:DO
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 810
Mailing Address - Street 2:
Mailing Address - City:WESTBROOK
Mailing Address - State:ME
Mailing Address - Zip Code:04098-0810
Mailing Address - Country:US
Mailing Address - Phone:207-854-1544
Mailing Address - Fax:207-854-1516
Practice Address - Street 1:379 METHODIST RD
Practice Address - Street 2:
Practice Address - City:WESTBROOK
Practice Address - State:ME
Practice Address - Zip Code:04092
Practice Address - Country:US
Practice Address - Phone:207-854-4638
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-17
Last Update Date:2008-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME1885204D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME1699888958OtherNPI
MEME2245Medicare PIN