Healthcare Provider Details

I. General information

NPI: 1952387326
Provider Name (Legal Business Name): JEFFREY J HOLMSTROM D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/19/2005
Last Update Date: 05/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

655 MAIN ST
SACO ME
04072-1543
US

IV. Provider business mailing address

655 MAIN ST
SACO ME
04072-1543
US

V. Phone/Fax

Practice location:
  • Phone: 207-283-1407
  • Fax: 207-284-6291
Mailing address:
  • Phone: 207-283-1407
  • Fax: 207-284-6291

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number1099
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: