Individual
DR. THOMAS J VANIDESTINE JR.
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
DC, CCSP
Contact information
Practice address
336 MOUNT HOPE AVE, SUITE 11, BANGOR, ME 04401-4236
(207) 942-2800
(207) 990-2362
Mailing address
336 MOUNT HOPE AVE, SUITE 11, BANGOR, ME 04401-4236
(207) 942-2800
(207) 990-2362
Taxonomy
Speciality
Code
Description
License number
State
111N00000X
Chiropractor
Primary
CR814
ME
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
001039
BLUE CROSS/ANTHEM
ME
05
—
121660000
—
ME
05
—
121660099
—
ME
01
—
5314274
AETNA
ME
01
—
5734579
CIGNA
ME
01
—
610664
GREAT WEST/ACN
ME
01
—
68974
FIRST HEALTH
ME
01
—
MN0080
HARVARD PILGRIM
ME
01
—
P00282285
RAILROAD MEDICARE
ME
Enumeration date
06/06/2006
Last updated
12/01/2016
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