Provider Demographics
NPI:1033161203
Name:DRIMALLA, RICHARD (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:DRIMALLA
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 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2211 E FRANKLIN BLVD
Practice Address - Street 2:STE 100
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-4985
Practice Address - Country:US
Practice Address - Phone:704-852-9561
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2021-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2011-01548208D00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1033161203Medicaid
MI4923497Medicaid
NC5919737Medicaid
SCNC1569Medicaid
NCNC5680IMedicare UPIN
NCNC5680JMedicare UPIN
NCNC5680LMedicare UPIN
MIP35490003Medicare PIN
NCNC5680MMedicare UPIN
MIB49098Medicare UPIN
NCNC5680HMedicare UPIN
NCNC5680NMedicare UPIN
NC5919737Medicaid
MI4923497Medicaid
SCNC1569Medicaid
NCNC5680OMedicare UPIN
NCNC5680KMedicare UPIN
NCNC5680AMedicare UPIN
NCNC5680BMedicare UPIN
NCNC5680CMedicare UPIN
NCNC5680GMedicare UPIN
NC1033161203Medicaid