Provider Demographics
NPI:1972547214
Name:WICKENDEN, ROGER W (MD)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:W
Last Name:WICKENDEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 GLEN COVE DR
Mailing Address - Street 2:SUITE 206
Mailing Address - City:ROCKPORT
Mailing Address - State:ME
Mailing Address - Zip Code:04856-4235
Mailing Address - Country:US
Mailing Address - Phone:207-593-5454
Mailing Address - Fax:207-593-5353
Practice Address - Street 1:4 GLEN COVE DR
Practice Address - Street 2:SUITE 206
Practice Address - City:ROCKPORT
Practice Address - State:ME
Practice Address - Zip Code:04856-4235
Practice Address - Country:US
Practice Address - Phone:207-593-5454
Practice Address - Fax:207-593-5353
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2010-09-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ME008520207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEMM0002Medicare ID - Type Unspecified
MEB86257Medicare UPIN