Provider Demographics
NPI:1275574311
Name:FANBURG, JONATHAN T (MD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:T
Last Name:FANBURG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301C US ROUTE 1
Mailing Address - Street 2:
Mailing Address - City:SCARBOROUGH
Mailing Address - State:ME
Mailing Address - Zip Code:04074-9701
Mailing Address - Country:US
Mailing Address - Phone:207-396-8600
Mailing Address - Fax:207-396-8632
Practice Address - Street 1:5 BUCKNAM ROAD
Practice Address - Street 2:SUITE 1D
Practice Address - City:FALMOUTH
Practice Address - State:ME
Practice Address - Zip Code:04105-1208
Practice Address - Country:US
Practice Address - Phone:207-781-1775
Practice Address - Fax:207-781-1780
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2012-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMD148782080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME282610099Medicaid
MEMM738102Medicare PIN
ME282610099Medicaid
MEMM738106Medicare PIN
MEMM738107Medicare PIN
MEMM7381Medicare PIN
MEG20164Medicare UPIN
MEP01038217Medicare PIN
MEMM738105Medicare PIN