Provider Demographics
NPI:1275630352
Name:DUTCH, JEFFERY J (OD)
Entity Type:Individual
Prefix:DR
First Name:JEFFERY
Middle Name:J
Last Name:DUTCH
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 209
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-0209
Mailing Address - Country:US
Mailing Address - Phone:207-338-1480
Mailing Address - Fax:207-338-1498
Practice Address - Street 1:94 HIGH ST
Practice Address - Street 2:
Practice Address - City:BELFAST
Practice Address - State:ME
Practice Address - Zip Code:04915-6344
Practice Address - Country:US
Practice Address - Phone:207-338-1480
Practice Address - Fax:207-338-1498
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2009-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEOPT576152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEP00313443OtherRMEDICARE
MEMM7987OtherPTAN#
ME245190099Medicaid
ME245190099Medicaid