Provider Demographics
NPI:1134452303
Name:PUCHOWICZ, MICHAEL JOSEPH (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JOSEPH
Last Name:PUCHOWICZ
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 1:4830 HIGHWAY 260
Mailing Address - Street 2:SUITE 102
Mailing Address - City:LAKESIDE
Mailing Address - State:AZ
Mailing Address - Zip Code:85929-5845
Mailing Address - Country:US
Mailing Address - Phone:928-537-1040
Mailing Address - Fax:928-537-1042
Practice Address - Street 1:4830 HIGHWAY 260
Practice Address - Street 2:SUITE 102
Practice Address - City:LAKESIDE
Practice Address - State:AZ
Practice Address - Zip Code:85929-5845
Practice Address - Country:US
Practice Address - Phone:928-537-1040
Practice Address - Fax:928-537-1042
Is Sole Proprietor?:No
Enumeration Date:2009-09-04
Last Update Date:2012-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ449402080S0010X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080S0010XAllopathic & Osteopathic PhysiciansPediatricsSports Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics