Provider Demographics
NPI:1912030743
Name:MEDICAL RTD INC
Entity Type:Organization
Organization Name:MEDICAL RTD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:TATYANA
Authorized Official - Middle Name:I
Authorized Official - Last Name:DATKHAEVA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:720-540-7155
Mailing Address - Street 1:7615 W 38TH AVE
Mailing Address - Street 2:UNIT B-123
Mailing Address - City:WHEAT RIDGE
Mailing Address - State:CO
Mailing Address - Zip Code:80033
Mailing Address - Country:US
Mailing Address - Phone:720-540-7155
Mailing Address - Fax:720-540-7155
Practice Address - Street 1:7615 W 38TH AVE
Practice Address - Street 2:UNIT B-123
Practice Address - City:WHEAT RIDGE
Practice Address - State:CO
Practice Address - Zip Code:80033-6172
Practice Address - Country:US
Practice Address - Phone:303-432-2776
Practice Address - Fax:303-432-2216
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-13
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO45108207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO45108OtherSTATE LICENSE
CO82709513Medicaid
CO82709513Medicaid
CO82709513Medicaid