Provider Demographics
NPI:1841294378
Name:DEMANGONE, MICHAEL J (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:J
Last Name:DEMANGONE
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:P.O. BOX 790
Mailing Address - Street 2:
Mailing Address - City:PAGE
Mailing Address - State:AZ
Mailing Address - Zip Code:86040-0790
Mailing Address - Country:US
Mailing Address - Phone:928-645-1607
Mailing Address - Fax:928-645-3254
Practice Address - Street 1:463 S LAKE POWELL BLVD
Practice Address - Street 2:
Practice Address - City:PAGE
Practice Address - State:AZ
Practice Address - Zip Code:86040-0790
Practice Address - Country:US
Practice Address - Phone:928-645-0945
Practice Address - Fax:928-645-3254
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-13
Last Update Date:2011-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ21633207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ141573Medicaid
AZF10989Medicare UPIN
AZ141573Medicaid
AZ65397Medicare ID - Type Unspecified