Provider Demographics
NPI:1336188150
Name:HIGGINBOTHAM, MICHAEL B (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:B
Last Name:HIGGINBOTHAM
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 1:2301 HOUSE AVE
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82001-3178
Mailing Address - Country:US
Mailing Address - Phone:307-635-4141
Mailing Address - Fax:307-635-6587
Practice Address - Street 1:2301 HOUSE AVE
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-3176
Practice Address - Country:US
Practice Address - Phone:307-635-4141
Practice Address - Fax:307-635-6587
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2013-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY6960A207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY119891200Medicaid
WY119891200Medicaid
WY10113Medicare ID - Type Unspecified