Provider Demographics
NPI:1477547461
Name:WOLKOWITZ, RICHARD M (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:M
Last Name:WOLKOWITZ
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 1:1000 RUSH DR
Mailing Address - Street 2:
Mailing Address - City:SALIDA
Mailing Address - State:CO
Mailing Address - Zip Code:81201-9627
Mailing Address - Country:US
Mailing Address - Phone:719-530-2000
Mailing Address - Fax:
Practice Address - Street 1:305 N KEENE ST
Practice Address - Street 2:SUITE 105
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-6897
Practice Address - Country:US
Practice Address - Phone:573-442-2299
Practice Address - Fax:573-442-1409
Is Sole Proprietor?:No
Enumeration Date:2005-09-06
Last Update Date:2021-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO108975207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO208000224Medicaid
MO917933907Medicare PIN
MO208000224Medicaid