Provider Demographics
NPI:1164458006
Name:THOMAS, MICHAEL I (DPM)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:I
Last Name:THOMAS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2620 KIT FOX CT
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80526-5283
Mailing Address - Country:US
Mailing Address - Phone:970-377-0113
Mailing Address - Fax:
Practice Address - Street 1:1355 RIVERSIDE AVE STE C
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80524-4366
Practice Address - Country:US
Practice Address - Phone:970-484-4620
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-23
Last Update Date:2017-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPOD.0000460213ES0103X, 213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY113903700Medicaid
CO01004605Medicaid
WYW309128Medicare PIN
WY113903700Medicaid
480017356Medicare ID - Type UnspecifiedPALMETTO GBA NUMBER
COCA1423Medicare ID - Type Unspecified
WYW308191Medicare ID - Type UnspecifiedADD'L WYO MEDICARE #