Provider Demographics
NPI:1265429369
Name:VAARDAHL, MICHAEL D (DPM)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:D
Last Name:VAARDAHL
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 1:1931 65TH AVE
Mailing Address - Street 2:STE A
Mailing Address - City:GREELEY
Mailing Address - State:CO
Mailing Address - Zip Code:80634-7945
Mailing Address - Country:US
Mailing Address - Phone:970-351-0900
Mailing Address - Fax:970-351-0940
Practice Address - Street 1:1931 65TH AVE
Practice Address - Street 2:STE A
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80634-7945
Practice Address - Country:US
Practice Address - Phone:970-351-0900
Practice Address - Fax:970-351-0940
Is Sole Proprietor?:No
Enumeration Date:2005-10-04
Last Update Date:2008-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO596213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO16254031Medicaid
COCA0483Medicare PIN
CO16254031Medicaid