Healthcare Provider Details

I. General information

NPI: 1861323131
Provider Name (Legal Business Name): SIMON JEFFREY DREISBACH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/26/2026
Last Update Date: 05/26/2026
Certification Date: 05/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

41 BURLINGTON MALL ROAD
BURLINGTON MA
01805-0001
US

IV. Provider business mailing address

473 REVERE BEACH PKWY
REVERE MA
02151-4082
US

V. Phone/Fax

Practice location:
  • Phone: 781-744-5100
  • Fax:
Mailing address:
  • Phone: 651-900-0659
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: