Provider Demographics
NPI:1447250352
Name:SCANLON, MICHAEL JAMES (DPM)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JAMES
Last Name:SCANLON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:162 MANSFIELD AVE APT A
Mailing Address - Street 2:
Mailing Address - City:WILLIMANTIC
Mailing Address - State:CT
Mailing Address - Zip Code:06226-2062
Mailing Address - Country:US
Mailing Address - Phone:860-456-4250
Mailing Address - Fax:860-456-3745
Practice Address - Street 1:162 MANSFIELD AVE APT A
Practice Address - Street 2:
Practice Address - City:WILLIMANTIC
Practice Address - State:CT
Practice Address - Zip Code:06226-2062
Practice Address - Country:US
Practice Address - Phone:860-456-4250
Practice Address - Fax:860-456-3745
Is Sole Proprietor?:No
Enumeration Date:2005-07-21
Last Update Date:2022-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT650213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTU55378Medicare UPIN