Basic Information
Provider Information | |||||||||
NPI: | 1528260262 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DUBES | ||||||||
FirstName: | MICHELLE | ||||||||
MiddleName: | LAI | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | LAI | ||||||||
OtherFirstName: | MICHELLE | ||||||||
OtherMiddleName: | KEM | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | M.D. | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 2323 W ROSE GARDEN LN | ||||||||
Address2: |   | ||||||||
City: | PHOENIX | ||||||||
State: | AZ | ||||||||
PostalCode: | 850272530 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6025216252 | ||||||||
FaxNumber: | 6238425640 | ||||||||
Practice Location | |||||||||
Address1: | 3501 N SCOTTSDALE RD | ||||||||
Address2: | SUITE 130 | ||||||||
City: | SCOTTSDALE | ||||||||
State: | AZ | ||||||||
PostalCode: | 852515648 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4804255000 | ||||||||
FaxNumber: | 4804255010 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/04/2007 | ||||||||
LastUpdateDate: | 02/18/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 41221 | AZ | Y |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
ID | Type | State | Issuer | Description | 429915 | 05 | AZ |   | MEDICAID | Z147448 | 01 |   | MEDICARE PTAN | OTHER | Z147449 | 01 |   | MEDICARE PTAN | OTHER |