Provider Demographics
NPI:1710059688
Name:DYKES, THOMAS A (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:A
Last Name:DYKES
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 1:324 GANNETT DR STE 200
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-3266
Mailing Address - Country:US
Mailing Address - Phone:207-482-7800
Mailing Address - Fax:
Practice Address - Street 1:22 BRAMHALL ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-3134
Practice Address - Country:US
Practice Address - Phone:207-662-2571
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2015-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMD133112085R0202X, 2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME337640099Medicaid
ME0005138173OtherAETNA
MEF75973Medicare UPIN
ME026367OtherANTHEM
MEMNT316OtherHPHC
MEMM5302Medicare ID - Type Unspecified
MEMM530201Medicare PIN
MEM94925OtherCIGNA
NH01Y003977NH01OtherANTHEM
ME2323471OtherAETNA USHC
NH30008333Medicaid
ME300061955Medicare ID - Type UnspecifiedRAILROAD
NHRE7126Medicare ID - Type Unspecified