Healthcare Provider Details

I. General information

NPI: 1235111048
Provider Name (Legal Business Name): JONATHAN DREIFUS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/17/2005
Last Update Date: 01/28/2025
Certification Date: 01/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

887 CONGRESS ST STE 400
PORTLAND ME
04102-3100
US

IV. Provider business mailing address

887 CONGRESS ST
PORTLAND ME
04102-3100
US

V. Phone/Fax

Practice location:
  • Phone: 207-774-6368
  • Fax: 207-662-7996
Mailing address:
  • Phone: 207-774-6368
  • Fax: 207-774-9388

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberMD13413
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: