Provider Demographics
NPI:1124035357
Name:VANNATTA, MICHAEL DAVID (DO)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:DAVID
Last Name:VANNATTA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1202 W HOWARD ST
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:IA
Mailing Address - Zip Code:50138-3103
Mailing Address - Country:US
Mailing Address - Phone:641-828-7211
Mailing Address - Fax:641-842-7030
Practice Address - Street 1:1202 W HOWARD ST
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:IA
Practice Address - Zip Code:50138-3103
Practice Address - Country:US
Practice Address - Phone:641-828-7211
Practice Address - Fax:641-842-7030
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2014-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA02160207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA45044OtherWELLMARK BC&BS IA
IA2039552Medicaid
IA3039552Medicaid
IA36316OtherWELLMARK BC&BS IA
IA198360054Medicare PIN
IA45044OtherWELLMARK BC&BS IA
IA3039552Medicaid