Provider Demographics
NPI:1316392079
Name:STODDARD, MICHAEL
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:STODDARD
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 1:4175 S ALAMO AVE
Mailing Address - Street 2:
Mailing Address - City:DAVIS-MONTHAN AFB
Mailing Address - State:AZ
Mailing Address - Zip Code:85707-4405
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4175 S ALAMO AVE
Practice Address - Street 2:
Practice Address - City:DAVIS-MONTHAN AFB
Practice Address - State:AZ
Practice Address - Zip Code:85707-4405
Practice Address - Country:US
Practice Address - Phone:520-228-4357
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-02
Last Update Date:2022-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
AZ608622084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program