Provider Demographics
NPI:1023056173
Name:RADWAY, PAUL RAYMOND (MD)
Entity type:Individual
Prefix:DR
First Name:PAUL
Middle Name:RAYMOND
Last Name:RADWAY
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 1:3506 SAN JOSE CT
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81005-3916
Mailing Address - Country:US
Mailing Address - Phone:719-252-6467
Mailing Address - Fax:
Practice Address - Street 1:3506 SAN JOSE CT
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81005-3916
Practice Address - Country:US
Practice Address - Phone:719-252-6467
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2015-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO20508208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO02974278Medicaid
CO02974278Medicaid
COD23794Medicare UPIN