Provider Demographics
NPI:1386175701
Name:O'BRIEN, MICHAEL WADE (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:WADE
Last Name:O'BRIEN
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 1:500 CHASE PKWY
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06708-3346
Mailing Address - Country:US
Mailing Address - Phone:203-755-6677
Mailing Address - Fax:203-573-9182
Practice Address - Street 1:500 CHASE PKWY
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06708-3346
Practice Address - Country:US
Practice Address - Phone:203-755-6677
Practice Address - Fax:203-573-9182
Is Sole Proprietor?:No
Enumeration Date:2017-03-27
Last Update Date:2024-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY63919390200000X
CT76983207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program