Healthcare Provider Details

I. General information

NPI: 1235478967
Provider Name (Legal Business Name): SOUTHERN MAINE EYE ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/31/2013
Last Update Date: 03/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

272 COTTAGE ST
SANFORD ME
04073-1815
US

IV. Provider business mailing address

272 COTTAGE ST
SANFORD ME
04073-1815
US

V. Phone/Fax

Practice location:
  • Phone: 207-324-7946
  • Fax: 207-636-5023
Mailing address:
  • Phone: 207-324-7946
  • Fax: 207-636-5023

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: EDWARD H JACCOMA
Title or Position: PHYSICIAN/OWNER
Credential: MD
Phone: 207-324-7946