Provider Demographics
NPI:1033460407
Name:STEAD, MICHAEL P
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:P
Last Name:STEAD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18W WYOMING AVE APT 12
Mailing Address - Street 2:
Mailing Address - City:MELROR E
Mailing Address - State:MA
Mailing Address - Zip Code:02176
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:18 W WYOMING AVE APT 12
Practice Address - Street 2:
Practice Address - City:MELROSE
Practice Address - State:MA
Practice Address - Zip Code:02176-4656
Practice Address - Country:US
Practice Address - Phone:617-797-8803
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-26
Last Update Date:2012-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAS55651656172V00000X, 174400000X
174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No172V00000XOther Service ProvidersCommunity Health Worker