Healthcare Provider Details

I. General information

NPI: 1295900165
Provider Name (Legal Business Name): MONTE G. MERRELL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2008
Last Update Date: 01/28/2020
Certification Date: 01/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 W. WHITE MOUNTAIN BLVD. SUITE D
LAKESIDE AZ
85929-7014
US

IV. Provider business mailing address

300 W. WHITE MOUNTAIN BLVD. SUITE D
LAKESIDE AZ
85929-7014
US

V. Phone/Fax

Practice location:
  • Phone: 928-368-4547
  • Fax: 928-368-4527
Mailing address:
  • Phone: 928-368-4547
  • Fax: 928-368-4527

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number107866
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number58018
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: