Basic Information
| Provider Information | |||||||||
| NPI: | 1871545210 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HAWKINS | ||||||||
| FirstName: | TRACY | ||||||||
| MiddleName: | BANSIDHAR | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | D.O | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | BANSIDHAR | ||||||||
| OtherFirstName: | TRACY | ||||||||
| OtherMiddleName: | JEAN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | D.O. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 28 BARNET AVE | ||||||||
| Address2: | |||||||||
| City: | WATERVILLE | ||||||||
| State: | ME | ||||||||
| PostalCode: | 049015102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2078735044 | ||||||||
| FaxNumber: | 2078734344 | ||||||||
| Practice Location | |||||||||
| Address1: | 25 FIRST PARK DR | ||||||||
| Address2: | SUITE A | ||||||||
| City: | OAKLAND | ||||||||
| State: | ME | ||||||||
| PostalCode: | 049635361 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2078734325 | ||||||||
| FaxNumber: | 2078734344 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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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 | 207R00000X | 1665 | ME | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 20A 7525 | CA | N | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.