Provider Demographics
NPI:1003897794
Name:DEPENBUSCH, MICHAEL J (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:DEPENBUSCH
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 1:1500 W RAY RD STE 1
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85224-0002
Mailing Address - Country:US
Mailing Address - Phone:480-963-3881
Mailing Address - Fax:480-899-8610
Practice Address - Street 1:1500 W RAY RD STE 1
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85224-0002
Practice Address - Country:US
Practice Address - Phone:480-963-3881
Practice Address - Fax:480-899-8610
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-09
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ30795207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZBD5433468OtherDEA
AZBD5433468OtherDEA