Provider Demographics
NPI:1629027370
Name:MAYER, RICHARD G (M D)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:G
Last Name:MAYER
Suffix:
Gender:M
Credentials:M D
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 3148
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46206-3148
Mailing Address - Country:US
Mailing Address - Phone:855-206-8407
Mailing Address - Fax:
Practice Address - Street 1:951 N WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:TITUSVILLE
Practice Address - State:FL
Practice Address - Zip Code:32796-2163
Practice Address - Country:US
Practice Address - Phone:321-268-6192
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-09
Last Update Date:2015-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME00504082085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL07178OtherBCBS NUMBER
FL300040319OtherRR MEDICARE
FL4892470001Medicaid
FL4892470001Medicaid
FL07178YMedicare PIN
FL07178ZMedicare PIN
FLD51870Medicare UPIN