Provider Demographics
NPI:1417926114
Name:WITHAM, RICHARD S (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:S
Last Name:WITHAM
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 1:250 N SHADELAND AVE
Mailing Address - Street 2:STE 130 PROVIDER ENROLLMENT
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:545 BARNHILL DR
Practice Address - Street 2:EH 500
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-5112
Practice Address - Country:US
Practice Address - Phone:317-274-3086
Practice Address - Fax:317-274-0241
Is Sole Proprietor?:No
Enumeration Date:2006-03-15
Last Update Date:2014-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01024020A208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000340403OtherBLUE CROSS
IN000000751683OtherANTHEM PIN
IN100186120Medicaid
IN000000751683OtherANTHEM PIN
IN000000340403OtherBLUE CROSS
D69762Medicare UPIN
IN100186120Medicaid