Provider Demographics
NPI:1073681938
Name:DYDA, STEPHEN M (DO)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:M
Last Name:DYDA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PROVIDER ENROLLMENT 41 MALL ROAD
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:01805-0001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:131 ORNAC
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:MA
Practice Address - Zip Code:01742-4181
Practice Address - Country:US
Practice Address - Phone:978-287-8767
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME271905207RC0000X
ME1909208M00000X
MA239929207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30223910Medicaid
MA110083133AMedicaid
ME432015499Medicaid
NH30223910Medicaid