Provider Demographics
NPI:1861697583
Name:DEROSIER, MEGHANN L (DO)
Entity type:Individual
Prefix:
First Name:MEGHANN
Middle Name:L
Last Name:DEROSIER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:69 MAIN ST STE 4
Mailing Address - Street 2:
Mailing Address - City:ORONO
Mailing Address - State:ME
Mailing Address - Zip Code:04473-4087
Mailing Address - Country:US
Mailing Address - Phone:207-962-1200
Mailing Address - Fax:407-602-0862
Practice Address - Street 1:44 HOGAN RD
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-5602
Practice Address - Country:US
Practice Address - Phone:207-942-2333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-21
Last Update Date:2021-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEDO2123208M00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME1679988737Medicaid
ME1629074075Medicaid
ME1861697583Medicaid
ME1558330506Medicaid