Provider Demographics
NPI:1093784308
Name:GUTHRIE, DALE W (MD)
Entity Type:Individual
Prefix:
First Name:DALE
Middle Name:W
Last Name:GUTHRIE
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 1:4540 E BASELINE RD
Mailing Address - Street 2:SUITE 108
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85206-4613
Mailing Address - Country:US
Mailing Address - Phone:480-892-3880
Mailing Address - Fax:480-545-4551
Practice Address - Street 1:4540 E BASELINE RD
Practice Address - Street 2:SUITE 108
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-4613
Practice Address - Country:US
Practice Address - Phone:480-892-3880
Practice Address - Fax:480-545-4551
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2008-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ17893208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ278417Medicaid
AZ278417-003Medicaid
AZE85923Medicare UPIN