Provider Demographics
NPI:1336136357
Name:MOOTHART, RICHARD W (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:W
Last Name:MOOTHART
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 1:2222 N NEVADA AVE
Mailing Address - Street 2:SUITE 4007
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80907-6831
Mailing Address - Country:US
Mailing Address - Phone:719-634-6671
Mailing Address - Fax:719-634-1448
Practice Address - Street 1:2222 N NEVADA AVE
Practice Address - Street 2:SUITE 4007
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80907-6831
Practice Address - Country:US
Practice Address - Phone:719-634-6671
Practice Address - Fax:719-634-1448
Is Sole Proprietor?:No
Enumeration Date:2005-10-04
Last Update Date:2009-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO16922207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01169226Medicaid
CO01169226Medicaid
COC11938Medicare PIN