Provider Demographics
NPI:1841330172
Name:DESERT PRAIRIE GYNECOLOGY AND OBSTETRICS PC
Entity type:Organization
Organization Name:DESERT PRAIRIE GYNECOLOGY AND OBSTETRICS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:W
Authorized Official - Last Name:PEARSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:928-289-3396
Mailing Address - Street 1:PO BOX 27
Mailing Address - Street 2:
Mailing Address - City:WINSLOW
Mailing Address - State:AZ
Mailing Address - Zip Code:86047-0027
Mailing Address - Country:US
Mailing Address - Phone:928-289-2647
Mailing Address - Fax:928-289-2333
Practice Address - Street 1:1500 N WILLIAMSON AVE
Practice Address - Street 2:
Practice Address - City:WINSLOW
Practice Address - State:AZ
Practice Address - Zip Code:86047-2736
Practice Address - Country:US
Practice Address - Phone:928-289-3396
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ13986261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ271875-04Medicaid