Provider Demographics
NPI:1316037146
Name:VASICEK, RICHARD E (DO)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:E
Last Name:VASICEK
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 763
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26507-0763
Mailing Address - Country:US
Mailing Address - Phone:800-541-4009
Mailing Address - Fax:
Practice Address - Street 1:177 MIDDLETOWN RD STE 1
Practice Address - Street 2:
Practice Address - City:FAIRMONT
Practice Address - State:WV
Practice Address - Zip Code:26554-8254
Practice Address - Country:US
Practice Address - Phone:304-363-6600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2022-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1552207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
000558950OtherBC
WV0010879001OtherMCAID WM LAB
WV0047267000Medicaid
WVVA0878833Medicare ID - Type Unspecified
WV0047267000Medicaid