Provider Demographics
NPI:1487658407
Name:MUTTY, RICHARD JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:JOHN
Last Name:MUTTY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1819 BLACK RIVER BLVD N
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:NY
Mailing Address - Zip Code:13440-2427
Mailing Address - Country:US
Mailing Address - Phone:315-336-5600
Mailing Address - Fax:315-336-5618
Practice Address - Street 1:1819 BLACK RIVER BLVD N
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:NY
Practice Address - Zip Code:13440-2427
Practice Address - Country:US
Practice Address - Phone:315-336-5600
Practice Address - Fax:315-336-5618
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-08
Last Update Date:2010-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY123964-1207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00520663Medicaid
NY00520663Medicaid
NYE86389Medicare UPIN