Provider Demographics
NPI:1700896149
Name:KOOTMAN, RICHARD M (MD, PC)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:M
Last Name:KOOTMAN
Suffix:
Gender:M
Credentials:MD, PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13943 N 91ST AVE BLDG G
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85381-3687
Mailing Address - Country:US
Mailing Address - Phone:623-561-1995
Mailing Address - Fax:623-561-2446
Practice Address - Street 1:13943 N 91ST AVE BLDG G
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85381-3687
Practice Address - Country:US
Practice Address - Phone:623-561-1995
Practice Address - Fax:623-561-2446
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-08
Last Update Date:2007-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ19610174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZE38049Medicare UPIN
AZZWCLFP01Medicare PIN