Provider Demographics
NPI:1649363805
Name:FAZELI, JABBAR (MD)
Entity type:Individual
Prefix:
First Name:JABBAR
Middle Name:
Last Name:FAZELI
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 1:22 W COLE RD STE 101
Mailing Address - Street 2:
Mailing Address - City:BIDDEFORD
Mailing Address - State:ME
Mailing Address - Zip Code:04005-9431
Mailing Address - Country:US
Mailing Address - Phone:207-780-6565
Mailing Address - Fax:
Practice Address - Street 1:22 W COLE RD STE 101
Practice Address - Street 2:
Practice Address - City:BIDDEFORD
Practice Address - State:ME
Practice Address - Zip Code:04005-9431
Practice Address - Country:US
Practice Address - Phone:207-780-6565
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2021-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME015513207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME227900099Medicaid
ME0035Medicare ID - Type Unspecified
H26236Medicare UPIN
ME227900099Medicaid