Provider Demographics
NPI:1952387326
Name:HOLMSTROM, JEFFREY J (DO)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:J
Last Name:HOLMSTROM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:655 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SACO
Mailing Address - State:ME
Mailing Address - Zip Code:04072-1543
Mailing Address - Country:US
Mailing Address - Phone:207-283-1407
Mailing Address - Fax:207-284-6291
Practice Address - Street 1:655 MAIN ST
Practice Address - Street 2:
Practice Address - City:SACO
Practice Address - State:ME
Practice Address - Zip Code:04072-1543
Practice Address - Country:US
Practice Address - Phone:207-283-1407
Practice Address - Fax:207-284-6291
Is Sole Proprietor?:No
Enumeration Date:2005-12-19
Last Update Date:2008-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME1099207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME293270099Medicaid
NH30224338Medicaid
MEB82880OtherHARVARD
MEMM4279OtherMEDICARE CLASS
NH30224338OtherEDS NH MEDICAID
MEM107799OtherCIGNA
ME003678OtherANTHEM
ME080190067OtherMEDICARE RR
MEB82880Medicare UPIN
NH30224338Medicaid