Provider Demographics
NPI:1750376927
Name:PANKOW, MICHAEL S (DC)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:S
Last Name:PANKOW
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 GENERAL BOOTH BLVD
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23454-5876
Mailing Address - Country:US
Mailing Address - Phone:757-490-0990
Mailing Address - Fax:
Practice Address - Street 1:2000 GENERAL BOOTH BLVD
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23454-5876
Practice Address - Country:US
Practice Address - Phone:757-490-0990
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-14
Last Update Date:2012-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0104000747111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA059152OtherBCBS
VA059152OtherBCBS
VAT21509Medicare UPIN