Provider Demographics
NPI:1447285762
Name:INGEBRETSEN, RICHARD J (MD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:J
Last Name:INGEBRETSEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 25535
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84125-0535
Mailing Address - Country:US
Mailing Address - Phone:866-898-7136
Mailing Address - Fax:616-975-9824
Practice Address - Street 1:1400 N 500 E
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341-2455
Practice Address - Country:US
Practice Address - Phone:435-716-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2010-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2752001205207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806567000Medicaid
UTD0842Medicaid
P00239282OtherRAILROAD MEDICARE
005592419Medicare PIN
ID806567000Medicaid