Provider Demographics
NPI:1689742603
Name:MICHAELS, STEPHEN THEODORE (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:THEODORE
Last Name:MICHAELS
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 1:25500 POINT LOOKOUT RD
Mailing Address - Street 2:
Mailing Address - City:LEONARDTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:20650-2015
Mailing Address - Country:US
Mailing Address - Phone:301-475-6082
Mailing Address - Fax:301-475-6475
Practice Address - Street 1:25500 POINT LOOKOUT RD
Practice Address - Street 2:
Practice Address - City:LEONARDTOWN
Practice Address - State:MD
Practice Address - Zip Code:20650-2015
Practice Address - Country:US
Practice Address - Phone:301-475-6082
Practice Address - Fax:301-475-6475
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2019-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0042845174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD182301900Medicaid
MD003424M27Medicare PIN
MD182301900Medicaid