Provider Demographics
NPI:1134261902
Name:VANTUYL, MICHAEL C (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:C
Last Name:VANTUYL
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 1:4180 GLENCLIFF AVENUE
Mailing Address - Street 2:
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86401
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:615 FAIRHURST ST
Practice Address - Street 2:
Practice Address - City:STERLING
Practice Address - State:CO
Practice Address - Zip Code:80751-4523
Practice Address - Country:US
Practice Address - Phone:970-526-5555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2017-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20100058622085R0001X
NV163032085R0001X
ND98332085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1134261902OtherBCBS OF AZ
AZ226346Medicaid
AZ5193524OtherAETNA PROVIDER #
AZ1134261902OtherMERCY CARE
NVV113341Medicare PIN
AZ5193524OtherAETNA PROVIDER #
AZ226346Medicaid