Provider Demographics
NPI:1659371524
Name:HACKENBERG, THOMAS A (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:A
Last Name:HACKENBERG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:3230 E WOODMEN RD
Mailing Address - Street 2:SUITE 210
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80920
Mailing Address - Country:US
Mailing Address - Phone:719-578-5176
Mailing Address - Fax:719-578-5188
Practice Address - Street 1:3230 E WOODMEN RD
Practice Address - Street 2:SUITE 210
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80920
Practice Address - Country:US
Practice Address - Phone:719-578-5176
Practice Address - Fax:719-578-5188
Is Sole Proprietor?:No
Enumeration Date:2005-07-21
Last Update Date:2013-06-11
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CO35232207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01352327Medicaid
CO0970329OtherAETNA
CO440001691OtherRAIL ROAD MEDICARE
CO41366OtherBLUE CROSS
CO440001691OtherRAIL ROAD MEDICARE
COG35055Medicare UPIN