Provider Demographics
NPI:1457328270
Name:COLQUITT, RICHARD DERRYL (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:DERRYL
Last Name:COLQUITT
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:PO BOX 15645
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89114-5645
Mailing Address - Country:US
Mailing Address - Phone:702-240-8847
Mailing Address - Fax:702-240-8790
Practice Address - Street 1:2300 W CHARLESTON BLVD
Practice Address - Street 2:STE 170
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89102
Practice Address - Country:US
Practice Address - Phone:702-877-8683
Practice Address - Fax:702-877-5249
Is Sole Proprietor?:No
Enumeration Date:2006-03-01
Last Update Date:2008-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV2329208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV2002076Medicaid
NV2002076Medicaid
NV35370Medicare ID - Type Unspecified