Provider Demographics
NPI:1013937390
Name:MOUCHANTAT, RICHARD A (MD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:A
Last Name:MOUCHANTAT
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 1:3280 WADSWORTH BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:WHEAT RIDGE
Mailing Address - State:CO
Mailing Address - Zip Code:80033-4628
Mailing Address - Country:US
Mailing Address - Phone:303-232-8585
Mailing Address - Fax:303-232-3304
Practice Address - Street 1:3280 WADSWORTH BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:WHEAT RIDGE
Practice Address - State:CO
Practice Address - Zip Code:80033-4628
Practice Address - Country:US
Practice Address - Phone:303-232-8585
Practice Address - Fax:303-232-3304
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2023-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.00337832086S0122X, 2086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01337831Medicaid
COG31660Medicare UPIN
COS4038Medicare ID - Type Unspecified