Provider Demographics
NPI:1114027570
Name:SIXON, JONATHAN WILFRED (MD)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:WILFRED
Last Name:SIXON
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:C/O ST MARY'S HEALTH SYSTEM - PROVIDER ENROLLMENT
Mailing Address - Street 2:PO BOX 7291
Mailing Address - City:LEWISTON
Mailing Address - State:ME
Mailing Address - Zip Code:04243-3100
Mailing Address - Country:US
Mailing Address - Phone:207-777-8695
Mailing Address - Fax:207-777-8800
Practice Address - Street 1:444 NASHUA ST
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:NH
Practice Address - Zip Code:03055-4915
Practice Address - Country:US
Practice Address - Phone:603-673-3014
Practice Address - Fax:603-672-7654
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2020-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH12080207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3073830Medicaid
NHRE7372Medicare ID - Type Unspecified
NH30203794Medicaid