Provider Demographics
NPI:1235196890
Name:BELCOURT, CRAIG L (MD)
Entity Type:Individual
Prefix:
First Name:CRAIG
Middle Name:L
Last Name:BELCOURT
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 1:3250 W LOWER BUCKEYE RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85009-6729
Mailing Address - Country:US
Mailing Address - Phone:480-285-9754
Mailing Address - Fax:480-272-7031
Practice Address - Street 1:3250 W LOWER BUCKEYE RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85009-6729
Practice Address - Country:US
Practice Address - Phone:480-285-9754
Practice Address - Fax:480-272-7031
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2011-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ34745207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ060491Medicaid
AZ060491Medicaid
AZ108848Medicare ID - Type Unspecified