Provider Demographics
NPI:1841610714
Name:MYTAR, JENNIFER O (DO)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:O
Last Name:MYTAR
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:O
Other - Last Name:MYTAR-LI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:6 GLEN COVE DR
Mailing Address - Street 2:
Mailing Address - City:ROCKPORT
Mailing Address - State:ME
Mailing Address - Zip Code:04856-4272
Mailing Address - Country:US
Mailing Address - Phone:207-301-8000
Mailing Address - Fax:
Practice Address - Street 1:6 GLEN COVE DR
Practice Address - Street 2:
Practice Address - City:ROCKPORT
Practice Address - State:ME
Practice Address - Zip Code:04856-4272
Practice Address - Country:US
Practice Address - Phone:207-301-8000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-18
Last Update Date:2025-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102205171207L00000X
OH58.005415207R00000X
390200000X
MEDO2956207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program