Provider Demographics
NPI:1306879325
Name:JICHA, DOUGLAS L (MD)
Entity type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:L
Last Name:JICHA
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:306 US ROUTE 1
Mailing Address - Street 2:BLDG C
Mailing Address - City:SCARBOROUGH
Mailing Address - State:ME
Mailing Address - Zip Code:04074
Mailing Address - Country:US
Mailing Address - Phone:207-885-5742
Mailing Address - Fax:207-885-1494
Practice Address - Street 1:306 US ROUTE 1
Practice Address - Street 2:BLDG C
Practice Address - City:SCARBOROUGH
Practice Address - State:ME
Practice Address - Zip Code:04074
Practice Address - Country:US
Practice Address - Phone:207-885-5742
Practice Address - Fax:207-885-1494
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2021-11-03
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
ME0068102086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME132540000Medicaid
MEME0128Medicare ID - Type Unspecified