Provider Demographics
NPI:1134183429
Name:LOCK, MICHELLE L (MD)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:L
Last Name:LOCK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:L
Other - Last Name:SORENSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:92 MONTVALE AVE
Mailing Address - Street 2:SUITE 4200
Mailing Address - City:STONEHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02180-3647
Mailing Address - Country:US
Mailing Address - Phone:781-451-0072
Mailing Address - Fax:781-451-0073
Practice Address - Street 1:92 MONTVALE AVE
Practice Address - Street 2:SUITE 4200
Practice Address - City:STONEHAM
Practice Address - State:MA
Practice Address - Zip Code:02180-3647
Practice Address - Country:US
Practice Address - Phone:781-451-0072
Practice Address - Fax:781-451-0073
Is Sole Proprietor?:No
Enumeration Date:2006-04-13
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA226036208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA226036OtherSTATE LICENSE
MA494236OtherTUFTS HEALTH PLAN
MAAA44091OtherHARVARD PILGRIM
MAJ29376OtherBLUE CROSS/BLUE SHIELD
MA0036396OtherNEIGHBORHOOD HEALTH PLAN
MABS9354274OtherDEA
MA494236OtherTUFTS HEALTH PLAN