Provider Demographics
NPI:1083651244
Name:STJERNHOLM, THOMAS CHRISTIAN (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:CHRISTIAN
Last Name:STJERNHOLM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3670 PARKER BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81008-2285
Mailing Address - Country:US
Mailing Address - Phone:719-564-1544
Mailing Address - Fax:719-924-1593
Practice Address - Street 1:3670 PARKER BLVD STE 101
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81008-2285
Practice Address - Country:US
Practice Address - Phone:719-564-1544
Practice Address - Fax:719-924-1593
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2013-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO19501207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01195015Medicaid
COP00997272OtherRAILROAD MEDICARE
COP00997272OtherRAILROAD MEDICARE