Healthcare Provider Details

I. General information

NPI: 1497804520
Provider Name (Legal Business Name): RICHARD A SHAND MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/09/2007
Last Update Date: 02/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 W 2ND ST
LA JUNTA CO
81050-1508
US

IV. Provider business mailing address

111 W 2ND ST P.O. BOX 496
LA JUNTA CO
81050-1508
US

V. Phone/Fax

Practice location:
  • Phone: 719-384-2771
  • Fax: 719-384-2077
Mailing address:
  • Phone: 719-384-2771
  • Fax: 719-384-2077

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number20661
License Number StateCO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier01206614
Identifier TypeMEDICAID
Identifier StateCO
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: