Provider Demographics
NPI:1881641272
Name:VINES, MICHAEL L (MD)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:L
Last Name:VINES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3003 N CENTRAL AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-2902
Mailing Address - Country:US
Mailing Address - Phone:602-685-6000
Mailing Address - Fax:602-685-6001
Practice Address - Street 1:3118 E MCDOWELL RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85008-3742
Practice Address - Country:US
Practice Address - Phone:602-685-6000
Practice Address - Fax:602-685-6001
Is Sole Proprietor?:No
Enumeration Date:2006-05-30
Last Update Date:2011-08-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ239922084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ431974Medicaid
AZ431974Medicaid