Provider Demographics
NPI:1902896590
Name:ALLEN, MICHELLE DEWOLF (DO)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:DEWOLF
Last Name:ALLEN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:LYN
Other - Last Name:DEWOLF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:PO BOX 16455
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85211-6455
Mailing Address - Country:US
Mailing Address - Phone:480-615-2075
Mailing Address - Fax:480-962-0523
Practice Address - Street 1:1220 S HIGLEY RD
Practice Address - Street 2:SUITE 101
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-4000
Practice Address - Country:US
Practice Address - Phone:480-615-2010
Practice Address - Fax:480-324-0950
Is Sole Proprietor?:No
Enumeration Date:2005-10-25
Last Update Date:2011-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3693208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ611641Medicaid
AZ611641Medicaid