Provider Demographics
NPI:1225079635
Name:CUTSHALL, BRENT M (MD)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:M
Last Name:CUTSHALL
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:PO BOX 967
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86002-0967
Mailing Address - Country:US
Mailing Address - Phone:928-773-0003
Mailing Address - Fax:928-773-1170
Practice Address - Street 1:1200 N BEAVER ST
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001
Practice Address - Country:US
Practice Address - Phone:928-773-0003
Practice Address - Fax:928-773-1170
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2019-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ38121207RP1001X, 207RC0200X
ORMD23817207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR227021Medicaid
AZ315682Medicaid
OR227021Medicaid
ORR115952Medicare ID - Type Unspecified
ORH84473Medicare UPIN