Provider Demographics
NPI:1740293968
Name:HUMPHERYS, DWIGHT (DO)
Entity type:Individual
Prefix:DR
First Name:DWIGHT
Middle Name:
Last Name:HUMPHERYS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 860
Mailing Address - Street 2:
Mailing Address - City:WHITERIVER
Mailing Address - State:AZ
Mailing Address - Zip Code:85941-0860
Mailing Address - Country:US
Mailing Address - Phone:928-338-4911
Mailing Address - Fax:928-338-5508
Practice Address - Street 1:200 WEST HOSPITAL DRIVE
Practice Address - Street 2:
Practice Address - City:WHITERIVER
Practice Address - State:AZ
Practice Address - Zip Code:85941
Practice Address - Country:US
Practice Address - Phone:928-338-3740
Practice Address - Fax:928-338-5508
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2013-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3820207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1427335181Medicaid
AZ20561Medicaid
AZ722737Medicaid
AZ1427335140Medicaid
8HC711Medicare UPIN
AZ1427335140Medicaid
8HC712Medicare UPIN