Provider Demographics
NPI:1720161250
Name:EARL, MICHAEL (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:EARL
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 1:1050 NORTH SAN FRANCISCO ST., STE D
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-3200
Mailing Address - Country:US
Mailing Address - Phone:928-774-1693
Mailing Address - Fax:928-774-3533
Practice Address - Street 1:1200 NORTH BEAVER ST
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-3200
Practice Address - Country:US
Practice Address - Phone:928-774-1693
Practice Address - Fax:928-774-3533
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ19713207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
412560OtherAHCCCS
E01334Medicare UPIN
412560OtherAHCCCS