Provider Demographics
NPI:1962469742
Name:STALLER, RICHARD LYLE (DO)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:LYLE
Last Name:STALLER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Mailing Address - Street 1:30940 STAGECOACH BLVD
Mailing Address - Street 2:SUITE E290
Mailing Address - City:EVERGREEN
Mailing Address - State:CO
Mailing Address - Zip Code:80439-7984
Mailing Address - Country:US
Mailing Address - Phone:303-674-8153
Mailing Address - Fax:303-674-8303
Practice Address - Street 1:30940 STAGECOACH BLVD
Practice Address - Street 2:SUITE E290
Practice Address - City:EVERGREEN
Practice Address - State:CO
Practice Address - Zip Code:80439-7984
Practice Address - Country:US
Practice Address - Phone:303-674-8153
Practice Address - Fax:303-674-8303
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CO25525207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01255256Medicaid
CO38662OtherBCBS
CO1016326OtherAETNA
COD24647Medicare UPIN
CO38662OtherBCBS