Healthcare Provider Details

I. General information

NPI: 1992125785
Provider Name (Legal Business Name): ELISABETH W. DEERAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/21/2014
Last Update Date: 01/14/2025
Certification Date: 01/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

84 MARGINAL WAY SUITE 900
PORTLAND ME
04101
US

IV. Provider business mailing address

100 GANNETT DRIVE SUITE C
SOUTH PORTLAND ME
04106-5900
US

V. Phone/Fax

Practice location:
  • Phone: 207-874-2445
  • Fax: 207-523-8598
Mailing address:
  • Phone: 207-828-0361
  • Fax: 207-874-1483

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberMD23051
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: