Healthcare Provider Details

I. General information

NPI: 1104853001
Provider Name (Legal Business Name): MATIJA M BURTIS DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2006
Last Update Date: 10/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 ANDOVER RD
PORTLAND ME
04102
US

IV. Provider business mailing address

190 RIVERSIDE STREET SUITE 6B
PORTLAND ME
04103
US

V. Phone/Fax

Practice location:
  • Phone: 207-661-6064
  • Fax: 207-253-6073
Mailing address:
  • Phone: 207-661-2095
  • Fax: 207-661-2033

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number1685
License Number StateME
# 2
Primary TaxonomyY
Taxonomy Code2083B0002X
TaxonomyObesity Medicine (Preventive Medicine) Physician
License NumberDO1685
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: