Provider Demographics
NPI:1619927522
Name:LIOTTA, RICHARD JOHN (DO)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:JOHN
Last Name:LIOTTA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:4585 NELSON BROGDON BLVD
Mailing Address - Street 2:
Mailing Address - City:SUGARHILL
Mailing Address - State:GA
Mailing Address - Zip Code:30518-3466
Mailing Address - Country:US
Mailing Address - Phone:770-932-0547
Mailing Address - Fax:770-932-4035
Practice Address - Street 1:4585 NELSON BROGDON BLVD
Practice Address - Street 2:
Practice Address - City:SUGARHILL
Practice Address - State:GA
Practice Address - Zip Code:30518-3466
Practice Address - Country:US
Practice Address - Phone:770-932-0547
Practice Address - Fax:770-932-4035
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2010-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA036408207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000656576BMedicaid
GA0100402OtherUNITED HEALTHCARE
GA752850OtherBLUE CROSS BLUE SHIELD
GA0880369013OtherCIGNA HEALTHCARE
GA4607419OtherAETNA MANAGED CARE
GA513138OtherAETNA HMO
GA752850OtherBLUE CROSS BLUE SHIELD
GA08BBRWGMedicare ID - Type Unspecified