Provider Demographics
NPI:1184615635
Name:WEATHERBEE, MARK B (OD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:B
Last Name:WEATHERBEE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 36
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:ME
Mailing Address - Zip Code:04457-0036
Mailing Address - Country:US
Mailing Address - Phone:207-794-2020
Mailing Address - Fax:207-794-8288
Practice Address - Street 1:26 ENFIELD RD
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:ME
Practice Address - Zip Code:04457-1190
Practice Address - Country:US
Practice Address - Phone:207-794-2020
Practice Address - Fax:207-794-8288
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-03
Last Update Date:2008-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEOPT617152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME0477200001OtherDME MEDICARE
MET31681Medicare UPIN
0477200001Medicare NSC
ME0477200001OtherDME MEDICARE