Provider Demographics
NPI:1629014949
Name:VANESIAN, RICHARD L (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:L
Last Name:VANESIAN
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 1:8401 JACK FINNEY BLVD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75402-3017
Mailing Address - Country:US
Mailing Address - Phone:800-945-2455
Mailing Address - Fax:
Practice Address - Street 1:1313 E OSBORN RD
Practice Address - Street 2:STE. 213
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85014-5678
Practice Address - Country:US
Practice Address - Phone:602-234-2601
Practice Address - Fax:602-234-3183
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2008-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ212832085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ118027145Medicaid
AZ118027145Medicaid
AZZ30WCHBR04Medicare PIN
AZ300025811Medicare PIN