Provider Demographics
NPI:1417998113
Name:MORAN, RICHARD A (DO)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:A
Last Name:MORAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10625 W NORTH AVE
Mailing Address - Street 2:102
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-2315
Mailing Address - Country:US
Mailing Address - Phone:414-877-5350
Mailing Address - Fax:414-877-5360
Practice Address - Street 1:5000 W CHAMBERS ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53210-1650
Practice Address - Country:US
Practice Address - Phone:262-691-1940
Practice Address - Fax:262-691-1126
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2017-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI33408207Q00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30061600Medicaid
WI0127Medicare PIN
WI30061600Medicaid
F77703Medicare UPIN