Provider Demographics
NPI:1144228420
Name:CAMPUZANO, KATIE MICHELE (MD)
Entity Type:Individual
Prefix:DR
First Name:KATIE
Middle Name:MICHELE
Last Name:CAMPUZANO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KATIE
Other - Middle Name:MICHELE
Other - Last Name:SHAW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:919 12TH PL
Mailing Address - Street 2:STE 1
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86305-1433
Mailing Address - Country:US
Mailing Address - Phone:928-778-4300
Mailing Address - Fax:928-771-0920
Practice Address - Street 1:9930 W INDIAN SCHOOL RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85037-5902
Practice Address - Country:US
Practice Address - Phone:623-846-7558
Practice Address - Fax:623-846-1674
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-12
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ31312207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ792855Medicaid
AZ70345Medicare ID - Type Unspecified
AZ792855Medicaid