Provider Demographics
NPI:1396853206
Name:RICHARDS, DAVID TAYLOR (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:TAYLOR
Last Name:RICHARDS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5249 GRAVENSTEIN PARK
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84123-4562
Mailing Address - Country:US
Mailing Address - Phone:801-262-2830
Mailing Address - Fax:888-893-1576
Practice Address - Street 1:175 N 100 W
Practice Address - Street 2:STE 202
Practice Address - City:VERNAL
Practice Address - State:UT
Practice Address - Zip Code:84078-2049
Practice Address - Country:US
Practice Address - Phone:435-789-4180
Practice Address - Fax:435-781-1185
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2011-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5586768-1205208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT558768120001OtherBLUE CROSS BLUE SHIELD
UT005770801/000057708OtherMEDICARE, UNSPECIFIED
UTB96455Medicare UPIN