Provider Demographics
NPI:1336231539
Name:DICAPUA, SAMUEL M (MS, DO, CHIE)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:M
Last Name:DICAPUA
Suffix:
Gender:M
Credentials:MS, DO, CHIE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 EXECUTIVE PARK DR
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:NH
Mailing Address - Zip Code:03110-6915
Mailing Address - Country:US
Mailing Address - Phone:603-200-5063
Mailing Address - Fax:
Practice Address - Street 1:2 EXECUTIVE PARK DR
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:NH
Practice Address - Zip Code:03110-6915
Practice Address - Country:US
Practice Address - Phone:603-200-5063
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2024-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL19852207Q00000X
ME1303207Q00000X
NH15867207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME100009224OtherGROUP TAX ID#
ME1174615371OtherGROUP NPI#
ME005725OtherANTHEM
ME431784599Medicaid
MEE69122Medicare UPIN
ME100009224OtherGROUP TAX ID#