Provider Demographics
NPI:1578550398
Name:HEADLEY, DON B (MD)
Entity Type:Individual
Prefix:
First Name:DON
Middle Name:B
Last Name:HEADLEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:FILE 56765
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90074-6765
Mailing Address - Country:US
Mailing Address - Phone:602-406-3860
Mailing Address - Fax:602-406-6132
Practice Address - Street 1:500 W THOMAS RD
Practice Address - Street 2:SUITE 900
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85013-4224
Practice Address - Country:US
Practice Address - Phone:602-406-3540
Practice Address - Fax:602-406-7186
Is Sole Proprietor?:No
Enumeration Date:2005-10-06
Last Update Date:2012-05-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ22079207YX0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YX0007XAllopathic & Osteopathic PhysiciansOtolaryngologyPlastic Surgery within the Head & Neck
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ165151Medicaid
AZP00452179OtherMEDICARE RAILROAD
AZAZ0779380OtherBLUE CROSS BLUE SHIELD
Z103977Medicare ID - Type Unspecified
AZP00452179OtherMEDICARE RAILROAD
AZAZ0779380OtherBLUE CROSS BLUE SHIELD