Provider Demographics
NPI:1083633580
Name:IANNESSA, MICHAEL JF (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JF
Last Name:IANNESSA
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 1:40 CHESTNUT ST
Mailing Address - Street 2:APT. #2
Mailing Address - City:CHARLESTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02129-3436
Mailing Address - Country:US
Mailing Address - Phone:781-254-1148
Mailing Address - Fax:
Practice Address - Street 1:1233 STATE RD
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02360-5133
Practice Address - Country:US
Practice Address - Phone:508-224-7701
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2012-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA52862207RA0401X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction Medicine
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3136248Medicaid
MA3136248Medicaid
MAJ03347Medicare ID - Type Unspecified