Provider Demographics
NPI:1033284724
Name:MCBRIDE, MICHAEL FULLER (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:FULLER
Last Name:MCBRIDE
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 1:1220 DEWEY AVE
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53213
Mailing Address - Country:US
Mailing Address - Phone:414-454-6610
Mailing Address - Fax:414-454-6644
Practice Address - Street 1:1220 DEWEY AVE
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53213
Practice Address - Country:US
Practice Address - Phone:414-454-6610
Practice Address - Fax:414-454-6644
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI346452084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
F60099Medicare UPIN