Provider Demographics
NPI:1013133628
Name:SIAHAAN, RICHARD (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:SIAHAAN
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 1:421 COTTAGE GROVE RD
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06002-3170
Mailing Address - Country:US
Mailing Address - Phone:860-242-0034
Mailing Address - Fax:860-242-3301
Practice Address - Street 1:421 COTTAGE GROVE RD
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:CT
Practice Address - Zip Code:06002-3170
Practice Address - Country:US
Practice Address - Phone:860-242-0034
Practice Address - Fax:860-242-3301
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2016-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT24303207R00000X
CT024303207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004263612OtherCHN
CT0V0438OtherHEALTHNET
PA7294618OtherCIGNA
CT704554OtherCONNECTICARE
CT004263612Medicaid
CT369877OtherWELLCARE
MA427750OtherTUFTS
CT80705OtherGREATWEST
CT010024303CT01OtherBLUESHIELD
TX514837OtherAETNA
CTP3592661OtherOXFORD
GA1751515OtherUNITED HEALTHCARE
CT0V0438OtherHEALTHNET
TX514837OtherAETNA