Basic Information
| Provider Information | |||||||||
| NPI: | 1891825022 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DOROZ | ||||||||
| FirstName: | MICHELLE | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3260 S MERRYVALE LN | ||||||||
| Address2: | |||||||||
| City: | FLAGSTAFF | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 860016567 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9285274325 | ||||||||
| FaxNumber: | 9285274327 | ||||||||
| Practice Location | |||||||||
| Address1: | 1501 S YALE ST | ||||||||
| Address2: | BLDG 2 SUITE 150 | ||||||||
| City: | FLAGSTAFF | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 860017304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9285274325 | ||||||||
| FaxNumber: | 9285274327 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/06/2007 | ||||||||
| LastUpdateDate: | 02/25/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 4045 | AZ | Y | Allopathic & Osteopathic Physicians | Family Medicine | 208D00000X | DR-50509 | CO | N | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 46408371 | 05 | CO | MEDICAID | 1902162753 | 01 | CO | BCBS | OTHER | 881038 | 05 | AZ | MEDICAID |