Basic Information
Provider Information | |||||||||
NPI: | 1316393093 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KISPERT | ||||||||
FirstName: | DAVID | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 235 MAIN ST | ||||||||
Address2: |   | ||||||||
City: | BIDDEFORD | ||||||||
State: | ME | ||||||||
PostalCode: | 040052411 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6033595249 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 235 MAIN ST | ||||||||
Address2: |   | ||||||||
City: | BIDDEFORD | ||||||||
State: | ME | ||||||||
PostalCode: | 040052411 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8442920111 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/11/2016 | ||||||||
LastUpdateDate: | 06/25/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/25/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 278749 | MA | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207RA0401X | MD23845 | ME | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Addiction Medicine |
No ID Information.