Provider Demographics
NPI:1386623403
Name:RENDLER, MICHAEL T (PC)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:T
Last Name:RENDLER
Suffix:
Gender:M
Credentials:PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 MICHIGAN ST
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81004-2138
Mailing Address - Country:US
Mailing Address - Phone:719-545-3555
Mailing Address - Fax:719-545-1517
Practice Address - Street 1:401 MICHIGAN ST
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81004-2138
Practice Address - Country:US
Practice Address - Phone:719-545-3555
Practice Address - Fax:719-545-1517
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-17
Last Update Date:2010-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO20267207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1528384161OtherBUSINESS NPI
CO71871853Medicaid
CO1386623403OtherPERSONAL NPI
CO1386623403OtherPERSONAL NPI
CO71871853Medicaid