Provider Demographics
NPI:1760456156
Name:PFANNENSTIEL, MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:PFANNENSTIEL
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 1:400 W 16TH ST
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81003-2745
Mailing Address - Country:US
Mailing Address - Phone:719-584-4306
Mailing Address - Fax:719-595-7886
Practice Address - Street 1:400 W 16TH ST
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81003-2745
Practice Address - Country:US
Practice Address - Phone:719-584-4306
Practice Address - Fax:719-595-7886
Is Sole Proprietor?:No
Enumeration Date:2006-02-14
Last Update Date:2012-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-31930207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200386410CMedicaid
KY64095748Medicaid
CO97424374Medicaid
KS200386410EMedicaid
KSP00445745OtherRR MEDICARE
KY64095748Medicaid
KSKA1398025Medicare PIN
KS200386410EMedicaid
COCOAAA2928Medicare PIN