Provider Demographics
NPI:1063458495
Name:DEFELICE, RICHARD DAVID (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:DAVID
Last Name:DEFELICE
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 1:1300 ETHAN WAY
Mailing Address - Street 2:SUITE 600
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95825-2296
Mailing Address - Country:US
Mailing Address - Phone:916-679-3590
Mailing Address - Fax:916-482-3647
Practice Address - Street 1:1508 ALHAMBRA BLVD STE 200
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95816-6510
Practice Address - Country:US
Practice Address - Phone:916-325-1040
Practice Address - Fax:916-669-4100
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2020-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG47183207RI0200X, 207RP1001X, 207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G471830Medicaid
CAA50616Medicare UPIN
CA00G471830Medicaid