Provider Demographics
NPI:1407876352
Name:RICHEY, MARK (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:RICHEY
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:P.O.1766
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46206-1766
Mailing Address - Country:US
Mailing Address - Phone:530-241-0473
Mailing Address - Fax:530-241-5377
Practice Address - Street 1:155 GLASSON WAY
Practice Address - Street 2:
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945-5723
Practice Address - Country:US
Practice Address - Phone:530-274-6107
Practice Address - Fax:530-274-6059
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2013-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG549422085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G549420Medicaid
CAE62600Medicare UPIN
CACV131ZMedicare PIN