Provider Demographics
NPI:1477556579
Name:SMITH, RICHARD GRAHAM (MD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:GRAHAM
Last Name:SMITH
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 1:1 MERCADO ST STE 100
Mailing Address - Street 2:
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81301-7300
Mailing Address - Country:US
Mailing Address - Phone:970-385-7977
Mailing Address - Fax:970-385-6727
Practice Address - Street 1:1 MERCADO ST STE 100
Practice Address - Street 2:
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81301-7300
Practice Address - Country:US
Practice Address - Phone:970-385-7977
Practice Address - Fax:970-385-6727
Is Sole Proprietor?:No
Enumeration Date:2005-05-23
Last Update Date:2008-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM94-146207RH0003X
CO40107207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM16505Medicaid
CO91941468Medicaid
UTT0240Medicaid
AZ191908Medicaid
CO91941468Medicaid
CO452288Medicare ID - Type Unspecified
C452288Medicare PIN