Provider Demographics
NPI:1174565667
Name:PICKUS, OWEN B (DO)
Entity type:Individual
Prefix:DR
First Name:OWEN
Middle Name:B
Last Name:PICKUS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 CHABOT ST
Mailing Address - Street 2:
Mailing Address - City:WESTBROOK
Mailing Address - State:ME
Mailing Address - Zip Code:04092-4817
Mailing Address - Country:US
Mailing Address - Phone:207-857-9311
Mailing Address - Fax:207-857-9324
Practice Address - Street 1:2 CHABOT ST
Practice Address - Street 2:
Practice Address - City:WESTBROOK
Practice Address - State:ME
Practice Address - Zip Code:04092-4817
Practice Address - Country:US
Practice Address - Phone:207-857-9311
Practice Address - Fax:207-857-9324
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-11
Last Update Date:2009-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME977207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME110890199Medicaid
MED99832Medicare UPIN