Provider Demographics
NPI:1174520852
Name:MAINELLA, MARK T (DO)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:T
Last Name:MAINELLA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Mailing Address - Street 1:24 MILES CENTER WAY
Mailing Address - Street 2:
Mailing Address - City:DAMARISCOTTA
Mailing Address - State:ME
Mailing Address - Zip Code:04543-4047
Mailing Address - Country:US
Mailing Address - Phone:207-563-4252
Mailing Address - Fax:207-563-4275
Practice Address - Street 1:24 MILES CENTER WAY
Practice Address - Street 2:
Practice Address - City:DAMARISCOTTA
Practice Address - State:ME
Practice Address - Zip Code:04543-4047
Practice Address - Country:US
Practice Address - Phone:207-563-4252
Practice Address - Fax:207-563-4275
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2018-10-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ME1799208600000X
MEDO1799208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME283930099Medicaid
H70154Medicare UPIN
ME283930099Medicaid