Basic Information
| Provider Information | |||||||||
| NPI: | 1427010644 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FUSON | ||||||||
| FirstName: | JEFFREY | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 69 | ||||||||
| Address2: | |||||||||
| City: | FARMINGTON | ||||||||
| State: | ME | ||||||||
| PostalCode: | 049380069 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2078978719 | ||||||||
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| Practice Location | |||||||||
| Address1: | 119 LIVERMORE FALLS RD | ||||||||
| Address2: | |||||||||
| City: | FARMINGTON | ||||||||
| State: | ME | ||||||||
| PostalCode: | 049386241 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2077786591 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/04/2006 | ||||||||
| LastUpdateDate: | 04/06/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 04/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 009849 | ME | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 231130000 | 05 | ME | MEDICAID |