Basic Information
| Provider Information | |||||||||
| NPI: | 1437231990 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KLISMITH | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5575 TECH CENTER DR | ||||||||
| Address2: | STE 106 | ||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809192353 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195901177 | ||||||||
| FaxNumber: | 7195901360 | ||||||||
| Practice Location | |||||||||
| Address1: | 550 W HIGHWAY 105 | ||||||||
| Address2: | |||||||||
| City: | MONUMENT | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801329122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7194889860 | ||||||||
| FaxNumber: | 7194889868 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/20/2006 | ||||||||
| LastUpdateDate: | 12/18/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/18/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 53709 | CO | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200111620A | 05 | OK | MEDICAID | 81177836 | 05 | CO | MEDICAID |