Provider Demographics
NPI:1548293772
Name:STOCKWELL, GEORGE W (DO)
Entity type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:W
Last Name:STOCKWELL
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 1:144 STATE ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04101-3776
Mailing Address - Country:US
Mailing Address - Phone:207-879-3000
Mailing Address - Fax:
Practice Address - Street 1:409 ROOSEVELT TRL
Practice Address - Street 2:
Practice Address - City:WINDHAM
Practice Address - State:ME
Practice Address - Zip Code:04062-4821
Practice Address - Country:US
Practice Address - Phone:207-893-0290
Practice Address - Fax:207-400-8633
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2012-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME1354207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME133040000Medicaid
ME133040000Medicaid