Provider Demographics
NPI:1194825828
Name:GALE, HARRY LAVERN II (DO)
Entity type:Individual
Prefix:DR
First Name:HARRY
Middle Name:LAVERN
Last Name:GALE
Suffix:II
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 1:450 S WILLARD ST STE 103
Mailing Address - Street 2:
Mailing Address - City:COTTONWOOD
Mailing Address - State:AZ
Mailing Address - Zip Code:86326-6744
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:450 S WILLARD ST STE 103
Practice Address - Street 2:
Practice Address - City:COTTONWOOD
Practice Address - State:AZ
Practice Address - Zip Code:86326-6744
Practice Address - Country:US
Practice Address - Phone:928-664-9573
Practice Address - Fax:928-634-0135
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-23
Last Update Date:2023-01-11
Deactivation Date:2021-05-20
Deactivation Code:
Reactivation Date:2021-10-28
Provider Licenses
StateLicense IDTaxonomies
AZ2772207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ137275002Medicaid
AZ137275002Medicaid