Provider Demographics
NPI:1093798720
Name:BLACK, RICHARD R (DO)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:R
Last Name:BLACK
Suffix:
Gender:M
Credentials:DO
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 89
Mailing Address - Street 2:
Mailing Address - City:CHAGRIN FALLS
Mailing Address - State:OH
Mailing Address - Zip Code:44022-0089
Mailing Address - Country:US
Mailing Address - Phone:216-245-0203
Mailing Address - Fax:440-893-9680
Practice Address - Street 1:28062 BAXTER RD
Practice Address - Street 2:
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92563-1401
Practice Address - Country:US
Practice Address - Phone:951-290-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-28
Last Update Date:2023-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34003488207R00000X, 207U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207U00000XAllopathic & Osteopathic PhysiciansNuclear Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0019707330001Medicaid
MD3312151 00OtherMEDICAID PTAN
WA8470726Medicaid
OHBL4212094OtherMEDICARE PTAN
OH0834262Medicaid
WA8470726Medicaid
PA0019707330001Medicaid
OHPTAN: 4212095Medicare PIN
OH0834262Medicaid