Healthcare Provider Details

I. General information

NPI: 1831148352
Provider Name (Legal Business Name): GREGORY MICHAEL SCHACKEL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/10/2006
Last Update Date: 03/26/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MERCADO ST SUITE 205
DURANGO CO
81301-7306
US

IV. Provider business mailing address

1 MERCADO ST SUITE 205
DURANGO CO
81301-7306
US

V. Phone/Fax

Practice location:
  • Phone: 970-385-7272
  • Fax: 970-385-7299
Mailing address:
  • Phone: 970-385-7272
  • Fax: 970-385-7299

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number44598
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number90296
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: