Provider Demographics
NPI:1609867779
Name:SPANN, RICHARD W (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:W
Last Name:SPANN
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 1:542N LONGFORD LN
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67206-1816
Mailing Address - Country:US
Mailing Address - Phone:316-634-2078
Mailing Address - Fax:
Practice Address - Street 1:3600 E HARRY ST
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67218-3713
Practice Address - Country:US
Practice Address - Phone:316-268-5000
Practice Address - Fax:316-689-5873
Is Sole Proprietor?:No
Enumeration Date:2005-10-28
Last Update Date:2015-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-13573261QP2300X, 261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100080790CMedicaid
KS100080790CMedicaid