Provider Demographics
NPI:1710036983
Name:ANFANG, MICHELLE KOSCHE (MD)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:KOSCHE
Last Name:ANFANG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 DWIGHT RD
Mailing Address - Street 2:
Mailing Address - City:LONGMEADOW
Mailing Address - State:MA
Mailing Address - Zip Code:01106-1748
Mailing Address - Country:US
Mailing Address - Phone:413-567-7842
Mailing Address - Fax:413-567-7842
Practice Address - Street 1:123 DWIGHT RD
Practice Address - Street 2:
Practice Address - City:LONGMEADOW
Practice Address - State:MA
Practice Address - Zip Code:01106-1748
Practice Address - Country:US
Practice Address - Phone:413-567-7842
Practice Address - Fax:413-567-7842
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-09
Last Update Date:2007-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA767932084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA11673OtherHEALTH NEW ENGLAND
MAJ14159Medicare UPIN
MAF66611Medicare ID - Type Unspecified