Provider Demographics
NPI:1518303569
Name:MEREDITH, RICHARD DANE (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:DANE
Last Name:MEREDITH
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 1:5171 S COTTONWOOD ST STE 400
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-5742
Mailing Address - Country:US
Mailing Address - Phone:801-507-3500
Mailing Address - Fax:
Practice Address - Street 1:5171 S COTTONWOOD ST STE 400
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84107-5742
Practice Address - Country:US
Practice Address - Phone:801-507-3500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-17
Last Update Date:2023-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT13150074-1205207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1518303569Medicaid