Provider Demographics
NPI:1609823202
Name:KNACKENDOFFEL, RICHARD ALAN (DO)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:ALAN
Last Name:KNACKENDOFFEL
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 1:2373 G RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81505-9641
Mailing Address - Country:US
Mailing Address - Phone:970-245-0484
Mailing Address - Fax:970-241-2803
Practice Address - Street 1:2373 G RD
Practice Address - Street 2:SUITE 100
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81505-9641
Practice Address - Country:US
Practice Address - Phone:970-245-0484
Practice Address - Fax:970-241-2803
Is Sole Proprietor?:No
Enumeration Date:2006-05-28
Last Update Date:2015-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO28231207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01282318Medicaid
D84562Medicare UPIN
CO92834Medicare ID - Type Unspecified