Provider Demographics
NPI:1639193550
Name:DOROTHEO, RICARDO R III (MD)
Entity Type:Individual
Prefix:DR
First Name:RICARDO
Middle Name:R
Last Name:DOROTHEO
Suffix:III
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 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1600 23RD ST
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:IN
Practice Address - Zip Code:47421-4704
Practice Address - Country:US
Practice Address - Phone:812-276-1240
Practice Address - Fax:812-276-1237
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2021-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01042508A207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200008310Medicaid
IN000000594471OtherBLUE SHIELD
IN131180IIIMedicare PIN
IN000000594471OtherBLUE SHIELD