Provider Demographics
NPI:1356313241
Name:CORDLE, RICHARD (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:CORDLE
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 1:3027 CIRCLE DR SW
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24018-2107
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4348 ELECTRIC RD
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24018-0720
Practice Address - Country:US
Practice Address - Phone:540-769-0976
Practice Address - Fax:540-857-5391
Is Sole Proprietor?:No
Enumeration Date:2006-02-03
Last Update Date:2021-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101-233252208000000X, 2080P0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0206XAllopathic & Osteopathic PhysiciansPediatricsPediatric Gastroenterology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010383722Medicaid
VA1356313241Medicaid
VA6702708Medicaid
VAH74499Medicare UPIN
000114C19Medicare PIN