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General NPI Number Information
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NPI Number | 1275574311
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Entity Type | Individual
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Provider Name | JONATHAN T FANBURG MD
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Gender | Male
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Dates
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Enumeration Date | 06/09/2006
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Last Update Date | 06/26/2012
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Provider Practice Location Address
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Address Line | 5 BUCKNAM ROAD SUITE 1D
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City | FALMOUTH
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State | ME
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Zip | 04105-1208
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Country | US
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Telephone | 207-781-1775
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Fax | 207-781-1780
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Provider Business Mailing Address
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Address Line | 301C US ROUTE 1
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City | SCARBOROUGH
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State | ME
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Zip | 04074-9701
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Country | US
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Telephone | 207-396-8600
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Fax | 207-396-8632
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2080A0000X
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Taxonomy Name | Pediatric Adolescent Medicine Physician
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License Number | MD14878
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License Number State | ME
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