Basic Information
| Provider Information | |||||||||
| NPI: | 1073681938 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DYDA | ||||||||
| FirstName: | STEPHEN | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 39 WALLACE AVE | ||||||||
| Address2: | |||||||||
| City: | SO PORTLAND | ||||||||
| State: | ME | ||||||||
| PostalCode: | 04106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2077610650 | ||||||||
| FaxNumber: | 2077618198 | ||||||||
| Practice Location | |||||||||
| Address1: | 131 ORNAC | ||||||||
| Address2: | |||||||||
| City: | CONCORD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 017424181 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9782878767 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2006 | ||||||||
| LastUpdateDate: | 11/06/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | 1909 | ME | N | Allopathic & Osteopathic Physicians | Hospitalist | 207RC0000X | 271905 | ME | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 30223910 | 05 | NH | MEDICAID | 432015499 | 05 | ME | MEDICAID | 110083133A | 05 | MA | MEDICAID |