Provider Demographics
NPI:1114938172
Name:RICHARD, ROBERT LAWRENCE (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:LAWRENCE
Last Name:RICHARD
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 658
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30503-0658
Mailing Address - Country:US
Mailing Address - Phone:770-718-1122
Mailing Address - Fax:770-533-4786
Practice Address - Street 1:3215 MCCLURE BRIDGE RD
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096-3223
Practice Address - Country:US
Practice Address - Phone:678-312-6200
Practice Address - Fax:678-312-6226
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2021-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA050992208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000948109DMedicaid
GA000948109JMedicaid
GA12483797OtherMULTIPLAN
GA348302OtherWELLCARE
GA000948109FMedicaid
GA000948109HMedicaid
GA000948109MMedicaid
GA7651335OtherCARE IMPROVEMENT PLUS
GA1114938172OtherTRICARE CERTIFIED
GA582117020056OtherTRICARE CERTIFIED
GA000948109CMedicaid
GA52895966OtherBCBS
GA582117020002OtherTRICARE CERTIFIED
GA000948109KMedicaid
GA01344195OtherAMERIGROUP
GA000948109LMedicaid
GA000948109NMedicaid
GAP01342975OtherPALMETTO GBA RAILROAD MEDICARE
GA0009481091Medicaid
GA000948109EMedicaid
GA000948109OMedicaid
GA110029C003330OtherTRAILBLAZER HEALTH ENTERPRISES
GA7573710OtherCIGNA