Basic Information
| Provider Information | |||||||||
| NPI: | 1477547461 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WOLKOWITZ | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | M. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 RUSH DR | ||||||||
| Address2: | |||||||||
| City: | SALIDA | ||||||||
| State: | CO | ||||||||
| PostalCode: | 812019627 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195302000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 305 N KEENE ST | ||||||||
| Address2: | SUITE 105 | ||||||||
| City: | COLUMBIA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 652016897 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5734422299 | ||||||||
| FaxNumber: | 5734421409 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/06/2005 | ||||||||
| LastUpdateDate: | 04/14/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP2900X | 108975 | MO | Y | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 208000224 | 05 | MO | MEDICAID |