Provider Demographics
NPI:1376835777
Name:MESA OTOLARYNGOLOGY PC
Entity Type:Organization
Organization Name:MESA OTOLARYNGOLOGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:HUFFAKER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:970-245-3333
Mailing Address - Street 1:1212 BOOKCLIFF AVE
Mailing Address - Street 2:
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81501-8162
Mailing Address - Country:US
Mailing Address - Phone:970-245-3333
Mailing Address - Fax:970-243-0414
Practice Address - Street 1:1212 BOOKCLIFF AVE
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81501-8162
Practice Address - Country:US
Practice Address - Phone:970-245-3333
Practice Address - Fax:970-243-0414
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-04
Last Update Date:2011-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO20189207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
COD23729Medicare UPIN