Provider Demographics
NPI:1508091281
Name:FELLERS, JONATHAN CARL (MD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:CARL
Last Name:FELLERS
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:PO BOX 2613
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04116-2613
Mailing Address - Country:US
Mailing Address - Phone:207-221-0635
Mailing Address - Fax:207-221-0634
Practice Address - Street 1:1 CITY CTR STE 8130
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-6420
Practice Address - Country:US
Practice Address - Phone:207-221-0635
Practice Address - Fax:207-221-0634
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-25
Last Update Date:2023-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMD206132084P0802X, 2084P0800X, 2083A0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2083A0300XAllopathic & Osteopathic PhysiciansPreventive MedicineAddiction Medicine