Healthcare Provider Details

I. General information

NPI: 1306879325
Provider Name (Legal Business Name): DOUGLAS L JICHA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 11/03/2021
Certification Date: 11/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

306 US ROUTE 1 BLDG C
SCARBOROUGH ME
04074
US

IV. Provider business mailing address

306 US ROUTE 1 BLDG C
SCARBOROUGH ME
04074
US

V. Phone/Fax

Practice location:
  • Phone: 207-885-5742
  • Fax: 207-885-1494
Mailing address:
  • Phone: 207-885-5742
  • Fax: 207-885-1494

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number006810
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: