Healthcare Provider Details

I. General information

NPI: 1245289966
Provider Name (Legal Business Name): MICHAEL JOHN STACKPOOL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2006
Last Update Date: 10/24/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8300 W. 38 AVE.
WHEAT RIDGE CO
80033
US

IV. Provider business mailing address

M185 1153 BERGEN PARKWAY
EVERGREEN CO
80439
US

V. Phone/Fax

Practice location:
  • Phone: 303-425-2087
  • Fax:
Mailing address:
  • Phone: 303-670-2264
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number35748
License Number StateCO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: