Basic Information
| Provider Information | |||||||||
| NPI: | 1649714742 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FULL CIRCLE DIRECT PRIMARY CARE | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 68 CHAPMAN ST | ||||||||
| Address2: | |||||||||
| City: | DAMARISCOTTA | ||||||||
| State: | ME | ||||||||
| PostalCode: | 045434614 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2075636616 | ||||||||
| FaxNumber: | 2075636625 | ||||||||
| Practice Location | |||||||||
| Address1: | 68 CHAPMAN ST | ||||||||
| Address2: | |||||||||
| City: | DAMARISCOTTA | ||||||||
| State: | ME | ||||||||
| PostalCode: | 045434614 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2075636616 | ||||||||
| FaxNumber: | 2075636625 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/07/2016 | ||||||||
| LastUpdateDate: | 12/13/2016 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GOLD | ||||||||
| AuthorizedOfficialFirstName: | MINDA | ||||||||
| AuthorizedOfficialMiddleName: | JANE | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2075636616 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD13738 | ME | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.