Basic Information
| Provider Information | |||||||||
| NPI: | 1740293968 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HUMPHERYS | ||||||||
| FirstName: | DWIGHT | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 860 | ||||||||
| Address2: | |||||||||
| City: | WHITERIVER | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 859410860 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9283384911 | ||||||||
| FaxNumber: | 9283385508 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 WEST HOSPITAL DRIVE | ||||||||
| Address2: | |||||||||
| City: | WHITERIVER | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85941 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9283383740 | ||||||||
| FaxNumber: | 9283385508 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2006 | ||||||||
| LastUpdateDate: | 03/14/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 3820 | AZ | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1427335181 | 05 | AZ | MEDICAID | 20561 | 05 | AZ | MEDICAID | 722737 | 05 | AZ | MEDICAID | 1427335140 | 05 | AZ | MEDICAID |