Provider Demographics
NPI:1588664031
Name:MOOREHEAD, RICHARD M (DPM)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:M
Last Name:MOOREHEAD
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6230
Mailing Address - Street 2:
Mailing Address - City:WHEELING
Mailing Address - State:WV
Mailing Address - Zip Code:26003-0722
Mailing Address - Country:US
Mailing Address - Phone:304-242-7106
Mailing Address - Fax:304-242-7108
Practice Address - Street 1:1061 MAIN ST
Practice Address - Street 2:
Practice Address - City:WHEELING
Practice Address - State:WV
Practice Address - Zip Code:26003-2701
Practice Address - Country:US
Practice Address - Phone:304-233-0500
Practice Address - Fax:304-233-0501
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-27
Last Update Date:2010-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV00156213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0100181000Medicaid
0428782Medicare PIN