Provider Demographics
NPI:1386699643
Name:LABENZ, MICHAEL J (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:LABENZ
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:DEPT 2018
Mailing Address - Street 2:PO BOX 29675
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85038-9675
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:77 W. FOREST AVENUE
Practice Address - Street 2:SUITE 101
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-1482
Practice Address - Country:US
Practice Address - Phone:928-773-2215
Practice Address - Fax:928-773-2240
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2011-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ284232085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ621442Medicaid
AZZ66284Medicare PIN
AZ300118004Medicare PIN
AZ621442Medicaid
AZZ72178Medicare PIN