Provider Demographics
NPI:1417150905
Name:STURDIVANT, RICHARD C (LMT)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:C
Last Name:STURDIVANT
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:MR
Other - First Name:RICK
Other - Middle Name:C
Other - Last Name:STURDIVANT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LMT
Mailing Address - Street 1:123 1ST ST
Mailing Address - Street 2:
Mailing Address - City:MELROSE
Mailing Address - State:FL
Mailing Address - Zip Code:32666-3030
Mailing Address - Country:US
Mailing Address - Phone:352-478-2300
Mailing Address - Fax:352-478-2300
Practice Address - Street 1:123 1ST ST
Practice Address - Street 2:
Practice Address - City:MELROSE
Practice Address - State:FL
Practice Address - Zip Code:32666-3030
Practice Address - Country:US
Practice Address - Phone:352-478-2300
Practice Address - Fax:352-478-2300
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA18359174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist