Healthcare Provider Details

I. General information

NPI: 1053388777
Provider Name (Legal Business Name): TAHIRA SAIFUDDIN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/01/2006
Last Update Date: 10/02/2024
Certification Date: 10/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

360 BROADWAY STE 100
BANGOR ME
04401-3985
US

IV. Provider business mailing address

11035 W SYCAMORE HILLS DR STE 1
FORT WAYNE IN
46814-9310
US

V. Phone/Fax

Practice location:
  • Phone: 207-907-3550
  • Fax: 207-907-3562
Mailing address:
  • Phone: 260-241-1233
  • Fax: 260-373-9740

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberMD23200
License Number StateME
# 2
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number01061185A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: