Healthcare Provider Details

I. General information

NPI: 1942795349
Provider Name (Legal Business Name): JACOB THOMAS MAHER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2018
Last Update Date: 09/30/2025
Certification Date: 09/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

240 INDIAN RIVER RD STE B1
ORANGE CT
06477
US

IV. Provider business mailing address

240 INDIAN RIVER RD STE B1
ORANGE CT
06477-3690
US

V. Phone/Fax

Practice location:
  • Phone: 203-795-6025
  • Fax: 203-799-1554
Mailing address:
  • Phone: 203-795-6025
  • Fax: 203-799-1554

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036160745
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number81218
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: