Provider Demographics
NPI:1851571590
Name:MATERN, RICHARD V (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:V
Last Name:MATERN
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:PO BOX 27128
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0128
Mailing Address - Country:US
Mailing Address - Phone:801-884-9728
Mailing Address - Fax:
Practice Address - Street 1:324 10TH AVE
Practice Address - Street 2:STE 100
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84103-2853
Practice Address - Country:US
Practice Address - Phone:801-408-3771
Practice Address - Fax:801-408-3772
Is Sole Proprietor?:No
Enumeration Date:2007-11-09
Last Update Date:2015-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.026474208800000X
UT6012531-1205208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000064259Medicare PIN