MEDICARE: MICHAEL STODDARD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program
2	2084P0800X	Psychiatry Physician	60862	AZ

General Provider Information

NPI Number	:	1316392079
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL STODDARD

Provider Business Mailing Address
First Line	:	4175 S ALAMO AVE
Second Line	:
City	:	DAVIS-MONTHAN AFB
State	:	AZ
Zip	:	85707-4405
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4175 S ALAMO AVE
Second Line	:
City	:	DAVIS-MONTHAN AFB
State	:	AZ
Zip	:	85707-4405
Country	:	US
Telephone Number	:	520-228-4357
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/02/2016
Last Update Date	:	02/04/2022

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Directions to “ MICHAEL STODDARD ” Practice Location

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