Provider Demographics
NPI:1336313311
Name:MASSICOTTE, STEPHEN JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:JOHN
Last Name:MASSICOTTE
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:3955 EAGLE CREEK PKWY
Mailing Address - Street 2:STE C
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46254-5615
Mailing Address - Country:US
Mailing Address - Phone:317-280-8410
Mailing Address - Fax:317-280-8414
Practice Address - Street 1:3955 EAGLE CREEK PKWY
Practice Address - Street 2:STE C
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46254-5615
Practice Address - Country:US
Practice Address - Phone:317-280-8410
Practice Address - Fax:317-280-8414
Is Sole Proprietor?:No
Enumeration Date:2008-04-21
Last Update Date:2024-04-16
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IN01039382A207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN164350Medicare PIN
INF01320Medicare UPIN