Provider Demographics
NPI:1700866696
Name:PRINGLE, EDGAR JAY (MD)
Entity Type:Individual
Prefix:
First Name:EDGAR
Middle Name:JAY
Last Name:PRINGLE
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 548
Mailing Address - Street 2:
Mailing Address - City:COTTONWOOD
Mailing Address - State:AZ
Mailing Address - Zip Code:86326-0548
Mailing Address - Country:US
Mailing Address - Phone:928-634-0665
Mailing Address - Fax:
Practice Address - Street 1:2200 E SHOW LOW LAKE RD
Practice Address - Street 2:
Practice Address - City:SHOW LOW
Practice Address - State:AZ
Practice Address - Zip Code:85901-7881
Practice Address - Country:US
Practice Address - Phone:928-537-6338
Practice Address - Fax:928-532-5947
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-18
Last Update Date:2007-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ125282085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ253724Medicaid
AZZWMBLJ02Medicare PIN
D00136Medicare UPIN