Provider Demographics
NPI:1780612762
Name:DREXELIUS, RICHARD JAY (MD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:JAY
Last Name:DREXELIUS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5434 E NICHOLS PL
Mailing Address - Street 2:
Mailing Address - City:CENTENNIAL
Mailing Address - State:CO
Mailing Address - Zip Code:80122-3800
Mailing Address - Country:US
Mailing Address - Phone:303-740-8630
Mailing Address - Fax:
Practice Address - Street 1:6909 S HOLLY CIR STE 100
Practice Address - Street 2:
Practice Address - City:CENTENNIAL
Practice Address - State:CO
Practice Address - Zip Code:80112-6300
Practice Address - Country:US
Practice Address - Phone:720-528-3559
Practice Address - Fax:720-528-9903
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2011-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO30924207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
F08426Medicare UPIN
432018Medicare ID - Type Unspecified