Provider Demographics
NPI:1578674818
Name:THORSEN, RICHARD DOUGLAS (MD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:DOUGLAS
Last Name:THORSEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:R. DOUGLAS
Other - Middle Name:
Other - Last Name:THORSEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:11215 DAKOTAH ST NW
Mailing Address - Street 2:
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55433-2563
Mailing Address - Country:US
Mailing Address - Phone:763-208-5182
Mailing Address - Fax:
Practice Address - Street 1:11215 DAKOTAH ST NW
Practice Address - Street 2:
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433-2563
Practice Address - Country:US
Practice Address - Phone:763-208-5182
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN24128207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN238098600Medicaid
MNA93567Medicare UPIN
MN238098600Medicaid
MNA93657Medicare UPIN