Provider Demographics
NPI:1114990751
Name:FOOTE, MICHAEL JAMES (DO)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JAMES
Last Name:FOOTE
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 2712
Mailing Address - Street 2:
Mailing Address - City:PINETOP
Mailing Address - State:AZ
Mailing Address - Zip Code:85935-2712
Mailing Address - Country:US
Mailing Address - Phone:928-242-0405
Mailing Address - Fax:
Practice Address - Street 1:3822 RUSTLER CIR
Practice Address - Street 2:
Practice Address - City:PINETOP
Practice Address - State:AZ
Practice Address - Zip Code:85935-8179
Practice Address - Country:US
Practice Address - Phone:928-242-0405
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-13
Last Update Date:2009-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4289207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ953564Medicaid
105113Medicare ID - Type Unspecified
AZ953564Medicaid