Basic Information
| Provider Information | |||||||||
| NPI: | 1346276342 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RICHTER | ||||||||
| FirstName: | JAY | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 311 WEST 14TH STREET | ||||||||
| Address2: | |||||||||
| City: | PUEBLO | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810032710 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195957585 | ||||||||
| FaxNumber: | 7195957589 | ||||||||
| Practice Location | |||||||||
| Address1: | 311 WEST 14TH STREET | ||||||||
| Address2: | |||||||||
| City: | PUEBLO | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810032710 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195957585 | ||||||||
| FaxNumber: | 7195957589 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2006 | ||||||||
| LastUpdateDate: | 06/25/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QA0505X | 26947 | CO | Y | Allopathic & Osteopathic Physicians | Family Medicine | Adult Medicine |
ID Information
| ID | Type | State | Issuer | Description | P01102035 | 01 | CO | RAILROAD MEDICARE | OTHER | 01269471 | 05 | CO | MEDICAID |