Provider Demographics
NPI:1922009372
Name:JANSON, RICHARD A (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:A
Last Name:JANSON
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 62
Mailing Address - Street 2:
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81502-0062
Mailing Address - Country:US
Mailing Address - Phone:970-255-6307
Mailing Address - Fax:970-244-7037
Practice Address - Street 1:1160 PATTERSON RD
Practice Address - Street 2:SUITE 201
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81506-8275
Practice Address - Country:US
Practice Address - Phone:970-255-6307
Practice Address - Fax:970-244-7037
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2007-11-18
Deactivation Date:2006-03-23
Deactivation Code:
Reactivation Date:2006-04-03
Provider Licenses
StateLicense IDTaxonomies
CODR-17729208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01177294Medicaid
COC809082Medicare PIN
COD28197Medicare UPIN