Healthcare Provider Details

I. General information

NPI: 1841330172
Provider Name (Legal Business Name): DESERT PRAIRIE GYNECOLOGY AND OBSTETRICS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/07/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 N WILLIAMSON AVE
WINSLOW AZ
86047-2736
US

IV. Provider business mailing address

PO BOX 27
WINSLOW AZ
86047-0027
US

V. Phone/Fax

Practice location:
  • Phone: 928-289-3396
  • Fax:
Mailing address:
  • Phone: 928-289-2647
  • Fax: 928-289-2333

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number13986
License Number StateAZ

VIII. Authorized Official

Name: MICHAEL W PEARSON
Title or Position: PRESIDENT
Credential: MD
Phone: 928-289-3396