Provider Demographics
NPI:1669622908
Name:FOX, MICHAEL DAVID (MD/PHD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:DAVID
Last Name:FOX
Suffix:
Gender:M
Credentials:MD/PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 MOULTON ST # 2
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:MA
Mailing Address - Zip Code:02462-1404
Mailing Address - Country:US
Mailing Address - Phone:314-365-7010
Mailing Address - Fax:
Practice Address - Street 1:330 BROOKLINE AVE
Practice Address - Street 2:KIRSTEIN #448
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215-5400
Practice Address - Country:US
Practice Address - Phone:617-667-0220
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-23
Last Update Date:2014-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20088018700207R00000X
MA2509182084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine