Provider Demographics
NPI:1427045889
Name:ARCHULETA, RICHARD DWAYNE (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:DWAYNE
Last Name:ARCHULETA
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 1:2114 STATE ROUTE 113 E
Mailing Address - Street 2:ZZZ ANESTHESIA
Mailing Address - City:MILAN
Mailing Address - State:OH
Mailing Address - Zip Code:44846-9483
Mailing Address - Country:US
Mailing Address - Phone:419-499-4500
Mailing Address - Fax:
Practice Address - Street 1:2114 STATE ROUTE 113 E
Practice Address - Street 2:ZZZ ANESTHESIA
Practice Address - City:MILAN
Practice Address - State:OH
Practice Address - Zip Code:44846-9483
Practice Address - Country:US
Practice Address - Phone:419-499-4500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-30
Last Update Date:2009-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301086457207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI104758286Medicaid
C37630056Medicare ID - Type Unspecified
MI104758286Medicaid