Provider Demographics
NPI:1437159233
Name:DICKENS, JOHN MARLEY (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:MARLEY
Last Name:DICKENS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 680
Mailing Address - Street 2:
Mailing Address - City:WALDOBORO
Mailing Address - State:ME
Mailing Address - Zip Code:04572-0680
Mailing Address - Country:US
Mailing Address - Phone:207-832-6394
Mailing Address - Fax:207-832-4392
Practice Address - Street 1:592 W MAIN ST
Practice Address - Street 2:
Practice Address - City:WALDOBORO
Practice Address - State:ME
Practice Address - Zip Code:04572-6030
Practice Address - Country:US
Practice Address - Phone:207-832-6394
Practice Address - Fax:207-832-4392
Is Sole Proprietor?:No
Enumeration Date:2005-07-22
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME11529208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME310640099Medicaid
AD1133470OtherDEA
D03685Medicare UPIN
ME310640099Medicaid