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General NPI Number Information
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NPI Number | 1306879325
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Entity Type | Individual
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Provider Name | DOUGLAS L JICHA MD
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Gender | Male
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Dates
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Enumeration Date | 07/10/2006
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Last Update Date | 11/03/2021
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Provider Practice Location Address
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Address Line | 306 US ROUTE 1 BLDG C
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City | SCARBOROUGH
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State | ME
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Zip | 04074
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Country | US
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Telephone | 207-885-5742
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Fax | 207-885-1494
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Provider Business Mailing Address
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Address Line | 306 US ROUTE 1 BLDG C
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City | SCARBOROUGH
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State | ME
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Zip | 04074
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Country | US
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Telephone | 207-885-5742
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Fax | 207-885-1494
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2086S0129X
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Taxonomy Name | Vascular Surgery Physician
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License Number | 006810
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License Number State | ME
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