Provider Demographics
NPI:1942437447
Name:EARLE, EMERSON M (IDMT)
Entity Type:Individual
Prefix:MR
First Name:EMERSON
Middle Name:M
Last Name:EARLE
Suffix:
Gender:M
Credentials:IDMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4625 S. PHOENIX ST
Mailing Address - Street 2:BLD 4843
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85707
Mailing Address - Country:US
Mailing Address - Phone:520-203-2666
Mailing Address - Fax:
Practice Address - Street 1:4625 S. PHOENIX ST
Practice Address - Street 2:BLD 4843
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85707
Practice Address - Country:US
Practice Address - Phone:520-203-2666
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-11
Last Update Date:2009-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians