Provider Demographics
NPI:1801842315
Name:PUSHKIN, RICHARD ISAAC (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:ISAAC
Last Name:PUSHKIN
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 1:324 10TH AVE
Mailing Address - Street 2:#285
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84103-2853
Mailing Address - Country:US
Mailing Address - Phone:801-408-1384
Mailing Address - Fax:
Practice Address - Street 1:324 10TH AVE
Practice Address - Street 2:#285
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84103-2853
Practice Address - Country:US
Practice Address - Phone:801-408-1384
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-26
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT54167551205207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAH12313Medicare UPIN
UT00507310Medicare ID - Type UnspecifiedPROVIDER