Provider Demographics
NPI:1033155353
Name:RICHARDS, CHARLES DAVID (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:DAVID
Last Name:RICHARDS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:C.
Other - Middle Name:DAVID
Other - Last Name:RICHARDS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1391 E FARM HILL DR
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84117-7354
Mailing Address - Country:US
Mailing Address - Phone:801-272-6859
Mailing Address - Fax:
Practice Address - Street 1:1391 E FARM HILL DR
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84117-7354
Practice Address - Country:US
Practice Address - Phone:801-272-6859
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-22
Last Update Date:2008-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1530211205208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTD99469Medicare UPIN
UT005539316Medicare ID - Type UnspecifiedPROVIDER
UT942854058761Medicare ID - Type UnspecifiedPROVIDER