Basic Information
| Provider Information | |||||||||
| NPI: | 1124035357 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VANNATTA | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | DAVID | ||||||||
| NamePrefix: | |||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1202 W HOWARD ST | ||||||||
| Address2: | |||||||||
| City: | KNOXVILLE | ||||||||
| State: | IA | ||||||||
| PostalCode: | 501383103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6418287211 | ||||||||
| FaxNumber: | 6418427030 | ||||||||
| Practice Location | |||||||||
| Address1: | 1202 W HOWARD ST | ||||||||
| Address2: | |||||||||
| City: | KNOXVILLE | ||||||||
| State: | IA | ||||||||
| PostalCode: | 501383103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6418287211 | ||||||||
| FaxNumber: | 6418427030 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2006 | ||||||||
| LastUpdateDate: | 01/07/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 02160 | IA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 45044 | 01 | IA | WELLMARK BC&BS IA | OTHER | 2039552 | 05 | IA | MEDICAID | 3039552 | 05 | IA | MEDICAID | 36316 | 01 | IA | WELLMARK BC&BS IA | OTHER |