Healthcare Provider Details

I. General information

NPI: 1679558274
Provider Name (Legal Business Name): MELISSA MCCORMACK MD, PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/07/2005
Last Update Date: 09/18/2020
Certification Date: 09/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

77 SWANTON ST STE 2
WINCHESTER MA
01890-2039
US

IV. Provider business mailing address

77 SWANTON ST STE 2
WINCHESTER MA
01890-2039
US

V. Phone/Fax

Practice location:
  • Phone: 781-922-4499
  • Fax:
Mailing address:
  • Phone: 781-922-4499
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number157278
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: