Provider Demographics
NPI:1073579074
Name:BICZAK, LAUREEN A (DO)
Entity Type:Individual
Prefix:
First Name:LAUREEN
Middle Name:A
Last Name:BICZAK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 GANNETT DR STE C
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-5900
Mailing Address - Country:US
Mailing Address - Phone:207-828-0361
Mailing Address - Fax:207-874-1483
Practice Address - Street 1:50 FODEN RD, STE 3
Practice Address - Street 2:
Practice Address - City:SOUTH PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106-1718
Practice Address - Country:US
Practice Address - Phone:207-774-5816
Practice Address - Fax:207-523-8594
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2019-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME1167207R00000X, 207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME265860099Medicaid
1041404OtherAETNA
018025OtherANTHEM
MM2978Medicare ID - Type Unspecified
MEMM297801Medicare PIN
018025OtherANTHEM