Basic Information
| Provider Information | |||||||||
| NPI: | 1053390609 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DICKENS | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD, MPH, SFHM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | LEWISTON | ||||||||
| State: | ME | ||||||||
| PostalCode: | 042407027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2077950111 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 300 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | LEWISTON | ||||||||
| State: | ME | ||||||||
| PostalCode: | 042407007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2077950111 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/12/2006 | ||||||||
| LastUpdateDate: | 10/08/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/08/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | DR.0064553 | CO | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 016935 | ME | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 016535 | 01 | ME | STSTE OF MAINE LICENSE | OTHER |