Provider Demographics
NPI:1003161035
Name:LACAZE, MICHAEL JAMES (DO)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JAMES
Last Name:LACAZE
Suffix:
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:PO BOX 10880
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86304-0880
Mailing Address - Country:US
Mailing Address - Phone:928-759-5987
Mailing Address - Fax:928-458-2039
Practice Address - Street 1:1050 GAIL GARDNER WAY STE 300
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86305-1640
Practice Address - Country:US
Practice Address - Phone:928-717-5232
Practice Address - Fax:928-717-5238
Is Sole Proprietor?:No
Enumeration Date:2012-07-16
Last Update Date:2022-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5315064402207Q00000X, 390200000X
AZ006806207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ192483Medicaid
AZ006806OtherAZ LICENSE
MI1003161035Medicaid