Provider Demographics
NPI:1538277868
Name:LAGEROOS, KENNETH W (DO)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:W
Last Name:LAGEROOS
Suffix:
Gender:M
Credentials:DO
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 7291
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ME
Mailing Address - Zip Code:04243-7291
Mailing Address - Country:US
Mailing Address - Phone:207-777-8950
Mailing Address - Fax:207-777-8800
Practice Address - Street 1:93 CAMPUS AVE
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ME
Practice Address - Zip Code:04240
Practice Address - Country:US
Practice Address - Phone:207-777-8442
Practice Address - Fax:207-777-8425
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-28
Last Update Date:2019-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEDO1227207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME037460OtherANTHEM BC/BS
ME325630099Medicaid
050064569OtherRAILROAD MEDICARE
ME037460OtherANTHEM BC/BS
050064569OtherRAILROAD MEDICARE