Provider Demographics
NPI:1023179371
Name:MENTZER, RICHARD LYNN JR (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:LYNN
Last Name:MENTZER
Suffix:JR
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 1:20270 BLACHLY GRANGE ROAD
Mailing Address - Street 2:
Mailing Address - City:BLACHLY
Mailing Address - State:OR
Mailing Address - Zip Code:97412
Mailing Address - Country:US
Mailing Address - Phone:541-925-4151
Mailing Address - Fax:541-925-3033
Practice Address - Street 1:20270 BLACHLY GRANGE ROAD
Practice Address - Street 2:
Practice Address - City:BLACHLY
Practice Address - State:OR
Practice Address - Zip Code:97412
Practice Address - Country:US
Practice Address - Phone:541-925-4151
Practice Address - Fax:541-925-3033
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2007-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD08548207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR196774Medicaid
R0000BHDLNMedicare ID - Type Unspecified
OR196774Medicaid