Healthcare Provider Details

I. General information

NPI: 1982652707
Provider Name (Legal Business Name): JONATHAN JAY MUSMAND MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2006
Last Update Date: 01/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

195 FORE RIVER PKWY SUITE 410
PORTLAND ME
04102-2780
US

IV. Provider business mailing address

195 FORE RIVER PKWY SUITE 410
PORTLAND ME
04102
US

V. Phone/Fax

Practice location:
  • Phone: 207-774-9839
  • Fax: 207-761-2127
Mailing address:
  • Phone: 207-774-9839
  • Fax: 207-761-2127

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number013825
License Number StateME
# 2
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number013825
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: