Provider Demographics
NPI:1053635508
Name:FAHERTY, LAURA J (MD, MPH, MSH)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:J
Last Name:FAHERTY
Suffix:
Gender:F
Credentials:MD, MPH, MSH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 BRAMHALL ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04102-3175
Mailing Address - Country:US
Mailing Address - Phone:207-662-2911
Mailing Address - Fax:617-568-4780
Practice Address - Street 1:22 BRAMHALL ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-3175
Practice Address - Country:US
Practice Address - Phone:207-662-2911
Practice Address - Fax:617-568-4780
Is Sole Proprietor?:No
Enumeration Date:2010-03-25
Last Update Date:2021-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMD23809208000000X
MA254089208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110095957AMedicaid
MA110095957AMedicaid