Provider Demographics
NPI:1215008784
Name:MARTIN, RICHARD WILLIAM (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:WILLIAM
Last Name:MARTIN
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 1:183 S 18TH AVE
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:CO
Mailing Address - Zip Code:80601-2472
Mailing Address - Country:US
Mailing Address - Phone:303-659-4248
Mailing Address - Fax:303-659-4283
Practice Address - Street 1:183 S 18TH AVE
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:CO
Practice Address - Zip Code:80601-2472
Practice Address - Country:US
Practice Address - Phone:303-659-4248
Practice Address - Fax:303-659-4283
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO30991208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01309913Medicaid