Provider Demographics
NPI:1568487627
Name:MYNATT, RICHARD J (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:J
Last Name:MYNATT
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 1:49 CLEVELAND ST STE 310
Mailing Address - Street 2:
Mailing Address - City:CROSSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38555-2854
Mailing Address - Country:US
Mailing Address - Phone:931-459-7720
Mailing Address - Fax:
Practice Address - Street 1:49 CLEVELAND ST STE 310
Practice Address - Street 2:
Practice Address - City:CROSSVILLE
Practice Address - State:TN
Practice Address - Zip Code:38555-2854
Practice Address - Country:US
Practice Address - Phone:931-459-7720
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-8938208800000X
AZ51180208800000X
NC24468208800000X
TN61647208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8961719Medicaid
TNQ060435Medicaid
AZ080427Medicaid
NC8961719Medicaid
AR376363YTBMMedicare PIN
NC2144395CMedicare PIN