Provider Demographics
NPI:1598723173
Name:PRATER, MICHAEL EDWARD (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:EDWARD
Last Name:PRATER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:1760 MCCULLOCH BLVD N
Mailing Address - Street 2:STE. 100
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86403-6559
Mailing Address - Country:US
Mailing Address - Phone:928-854-5368
Mailing Address - Fax:928-854-4462
Practice Address - Street 1:1760 MCCULLOCH BLVD N
Practice Address - Street 2:STE. 100
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-6559
Practice Address - Country:US
Practice Address - Phone:928-854-5368
Practice Address - Fax:928-854-4462
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2008-03-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ28430207Y00000X, 207YX0602X, 207YX0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No207YX0602XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngic Allergy
No207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ515877Medicaid
AZ515877Medicaid
AZG56464Medicare UPIN