Provider Demographics
NPI:1356592943
Name:SQUIRE, MICHAEL LOUIS (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:LOUIS
Last Name:SQUIRE
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 1:2624 RIDGEWAY CIR
Mailing Address - Street 2:
Mailing Address - City:JONES
Mailing Address - State:OK
Mailing Address - Zip Code:73049-4971
Mailing Address - Country:US
Mailing Address - Phone:630-297-5302
Mailing Address - Fax:
Practice Address - Street 1:2624 RIDGEWAY CIR
Practice Address - Street 2:
Practice Address - City:JONES
Practice Address - State:OK
Practice Address - Zip Code:73049-4971
Practice Address - Country:US
Practice Address - Phone:630-297-5302
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-01
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-131572085B0100X, 2085R0202X, 2085R0204X
WAMD604612652085B0100X, 2085R0204X, 2085R0202X
GA0724522085R0202X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0385157OtherL&I-SOUTH SOUND RADIOLOGY
WA0353469OtherL&I-RADIA KING CTY
WA2044272Medicaid
WA0353470OtherL&I-SWEDISH RADIA EDMONDS
WA0353472OtherL&I-EVERGREEN RADIA
ID1356592943Medicaid
WA0353429OtherL&I-RADIA REST OF WA
WA0405139OtherL&I-SEATTLE RADIOLOGY