Healthcare Provider Details

I. General information

NPI: 1023006194
Provider Name (Legal Business Name): JEFFREY DEAN PITTIS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/12/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

90 RIDGEWOOD DR
BANGOR ME
04401-2652
US

IV. Provider business mailing address

90 RIDGEWOOD DR
BANGOR ME
04401-2652
US

V. Phone/Fax

Practice location:
  • Phone: 207-942-0669
  • Fax: 207-947-3143
Mailing address:
  • Phone: 207-942-0669
  • Fax: 207-947-3143

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberME013153
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: