Provider Demographics
NPI:1598852634
Name:EID, JESSICA NOELLE (DO)
Entity Type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:NOELLE
Last Name:EID
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:JESSICA
Other - Middle Name:NOELLE
Other - Last Name:FOOTE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:25A JUNE ST STE 111
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:ME
Mailing Address - Zip Code:04073-2642
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:25A JUNE ST STE 111
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:ME
Practice Address - Zip Code:04073
Practice Address - Country:US
Practice Address - Phone:207-490-7998
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-09
Last Update Date:2019-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEDO2856207R00000X
ORDO27647207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR006214Medicaid
WA1092221Medicaid
OR138545Medicare PIN
OR006214Medicaid
WAG8962124Medicare PIN
OR142699Medicare PIN
ORRES000Medicare UPIN
OR138544Medicare PIN