Provider Demographics
NPI:1609257062
Name:PRIM, MICHAEL DYTON (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:DYTON
Last Name:PRIM
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 1:4360 E GRANADA RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85008-4091
Mailing Address - Country:US
Mailing Address - Phone:254-315-6626
Mailing Address - Fax:
Practice Address - Street 1:1111 E MCDOWELL RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85006-2612
Practice Address - Country:US
Practice Address - Phone:602-839-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-11
Last Update Date:2022-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
AZ66227207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program