Provider Demographics
NPI:1932188323
Name:VAN MOURIK, FREDERICK A
Entity type:Individual
Prefix:
First Name:FREDERICK
Middle Name:A
Last Name:VAN MOURIK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 SHAKER RD
Mailing Address - Street 2:GRAY
Mailing Address - City:GRAY
Mailing Address - State:ME
Mailing Address - Zip Code:04039-9629
Mailing Address - Country:US
Mailing Address - Phone:207-657-3308
Mailing Address - Fax:207-657-3309
Practice Address - Street 1:116 SHAKER RD
Practice Address - Street 2:GRAY
Practice Address - City:GRAY
Practice Address - State:ME
Practice Address - Zip Code:04039-9629
Practice Address - Country:US
Practice Address - Phone:207-657-3308
Practice Address - Fax:207-657-3309
Is Sole Proprietor?:No
Enumeration Date:2006-01-13
Last Update Date:2008-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME12383207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME000203013Medicaid
ME000203013Medicaid
MEB86438Medicare UPIN