Provider Demographics
NPI:1003893843
Name:PENLAND, RICHARD W
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:W
Last Name:PENLAND
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:RICHARD
Other - Middle Name:W
Other - Last Name:PENLAND
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 17284
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80217-0284
Mailing Address - Country:US
Mailing Address - Phone:303-306-7783
Mailing Address - Fax:303-306-7753
Practice Address - Street 1:1501 S POTOMAC ST
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80012-5411
Practice Address - Country:US
Practice Address - Phone:303-695-2628
Practice Address - Fax:303-306-7753
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2016-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI15310208000000X
CODR.0036239207PP0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PP0204XAllopathic & Osteopathic PhysiciansEmergency MedicinePediatric Emergency Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01362391Medicaid
COG51972Medicare UPIN
CO01362391Medicaid