Basic Information
| Provider Information | |||||||||
| NPI: | 1063417517 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HIGGINS | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 26 SCHOOL ST | ||||||||
| Address2: | STE 1 | ||||||||
| City: | YARMOUTH | ||||||||
| State: | ME | ||||||||
| PostalCode: | 040964710 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2078473800 | ||||||||
| FaxNumber: | 2078473802 | ||||||||
| Practice Location | |||||||||
| Address1: | 26 SCHOOL ST | ||||||||
| Address2: | |||||||||
| City: | YARMOUTH | ||||||||
| State: | ME | ||||||||
| PostalCode: | 040964709 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2078541544 | ||||||||
| FaxNumber: | 2078541516 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2005 | ||||||||
| LastUpdateDate: | 12/03/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | OPT873 | ME | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 3559581 | 01 | ME | AETNA | OTHER | 412330099 | 05 | ME | MEDICAID | 1689835845 | 01 | ME | GROUP NPI # | OTHER | 023030 | 01 | ME | ANTHEMBCBS | OTHER |