Provider Demographics
NPI:1053795278
Name:DR. GARY DEGEN LLC
Entity type:Organization
Organization Name:DR. GARY DEGEN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:P
Authorized Official - Last Name:DEGEN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:502-475-1915
Mailing Address - Street 1:26 WOODVIEW DR
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-3541
Mailing Address - Country:US
Mailing Address - Phone:502-475-1915
Mailing Address - Fax:
Practice Address - Street 1:26 WOODVIEW DR
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-3541
Practice Address - Country:US
Practice Address - Phone:502-475-1915
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-17
Last Update Date:2015-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME#POD1023261QP1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME393606Medicare UPIN