Basic Information
Provider Information | |||||||||
NPI: | 1104098110 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WITHERS | ||||||||
FirstName: | LAURA | ||||||||
MiddleName: | TERESA | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | GIDEON WITHERS | ||||||||
OtherFirstName: | LAURA | ||||||||
OtherMiddleName: | TERESA | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | M.D. | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 110 MARGINAL WAY | ||||||||
Address2: |   | ||||||||
City: | PORTLAND | ||||||||
State: | ME | ||||||||
PostalCode: | 041012442 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9176505408 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 887 CONGRESS ST STE 210 | ||||||||
Address2: |   | ||||||||
City: | PORTLAND | ||||||||
State: | ME | ||||||||
PostalCode: | 041023166 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2077742381 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/31/2008 | ||||||||
LastUpdateDate: | 04/02/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/02/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 602330543 | WA | N |   | Allopathic & Osteopathic Physicians | Surgery |   | 2086S0102X | ME102332 | FL | N |   | Allopathic & Osteopathic Physicians | Surgery | Surgical Critical Care | 2086S0127X | 602330543 | WA | N |   | Allopathic & Osteopathic Physicians | Surgery | Trauma Surgery | 208600000X | 002800501 | ME | Y |   | Allopathic & Osteopathic Physicians | Surgery |   |
No ID Information.