Provider Demographics
NPI:1073512745
Name:ROSENTHAL, RICHARD M (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:M
Last Name:ROSENTHAL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3585 N UNIVERSITY AVE STE 150
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-6630
Mailing Address - Country:US
Mailing Address - Phone:801-356-6100
Mailing Address - Fax:801-356-2113
Practice Address - Street 1:3585 N UNIVERSITY AVE STE 150
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-6630
Practice Address - Country:US
Practice Address - Phone:801-356-6100
Practice Address - Fax:801-356-2113
Is Sole Proprietor?:No
Enumeration Date:2005-07-15
Last Update Date:2011-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT180329-1205208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTE35545Medicare UPIN
UT005734301Medicare ID - Type Unspecified