Provider Demographics
NPI:1902887185
Name:MEDLOCK, MICHAEL DEAN (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:DEAN
Last Name:MEDLOCK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43 TURNING MILL RD
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:02420-1319
Mailing Address - Country:US
Mailing Address - Phone:617-833-8928
Mailing Address - Fax:
Practice Address - Street 1:47 CONGRESS ST
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:MA
Practice Address - Zip Code:01970
Practice Address - Country:US
Practice Address - Phone:978-744-8388
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-07
Last Update Date:2022-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA79690207T00000X, 208000000X, 2083A0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083A0300XAllopathic & Osteopathic PhysiciansPreventive MedicineAddiction Medicine
No207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA11000546AMedicaid
MA079690OtherTUFTS HEALTH PLAN
MAJ22399OtherBCBS MA
MAJ22399OtherBCBS MA
E29333Medicare UPIN