Provider Demographics
NPI:1861831075
Name:MYCHAK, ASHLEY E (DPM)
Entity type:Individual
Prefix:
First Name:ASHLEY
Middle Name:E
Last Name:MYCHAK
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 GLEN COVE DR STE 205
Mailing Address - Street 2:
Mailing Address - City:ROCKPORT
Mailing Address - State:ME
Mailing Address - Zip Code:04856-4237
Mailing Address - Country:US
Mailing Address - Phone:207-301-5700
Mailing Address - Fax:207-301-5370
Practice Address - Street 1:4 GLEN COVE DR STE 205
Practice Address - Street 2:
Practice Address - City:ROCKPORT
Practice Address - State:ME
Practice Address - Zip Code:04856-4237
Practice Address - Country:US
Practice Address - Phone:207-301-5700
Practice Address - Fax:207-301-5370
Is Sole Proprietor?:No
Enumeration Date:2013-06-20
Last Update Date:2025-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36-003866213ES0103X
MEPOD1109213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0262019Medicaid