Healthcare Provider Details

I. General information

NPI: 1174502090
Provider Name (Legal Business Name): RICHARD JAMES SERKOWSKI DO, MPH, CPE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2006
Last Update Date: 03/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

511 N TORCH BLVD BLDG 300
CANNON AFB NM
88103-5109
US

IV. Provider business mailing address

1599 J ST BLDG 109
GRAND FORKS AFB ND
58205-6332
US

V. Phone/Fax

Practice location:
  • Phone: 575-784-0287
  • Fax:
Mailing address:
  • Phone: 701-747-5547
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number42767-021
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code2083A0100X
TaxonomyAerospace Medicine Physician
License Number42767
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: