Provider Demographics
NPI:1295231769
Name:KNABEL, MICHAEL JOHN
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JOHN
Last Name:KNABEL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:169 ASHLEY AVENUE
Mailing Address - Street 2:ROOM 202 MAIN HOSPITAL, MSC333
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29425-8905
Mailing Address - Country:US
Mailing Address - Phone:843-792-3121
Mailing Address - Fax:
Practice Address - Street 1:12831 N PORT WASHINGTON RD
Practice Address - Street 2:
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53097-2400
Practice Address - Country:US
Practice Address - Phone:262-643-1300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-03
Last Update Date:2024-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125.075232207N00000X
SCMMD.87404207ND0900X
WI82136207ND0900X, 207N00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program