Provider Demographics
NPI:1659331627
Name:MINIELLY, RICHARD WESLEY (MD)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:WESLEY
Last Name:MINIELLY
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 1:63 OFFICE PARK DRIVE
Mailing Address - Street 2:
Mailing Address - City:ROANOKE RAPIDS
Mailing Address - State:NC
Mailing Address - Zip Code:27870
Mailing Address - Country:US
Mailing Address - Phone:252-535-4343
Mailing Address - Fax:252-308-0977
Practice Address - Street 1:63 OFFICE PARK DRIVE
Practice Address - Street 2:
Practice Address - City:ROANOKE RAPIDS
Practice Address - State:NC
Practice Address - Zip Code:27870
Practice Address - Country:US
Practice Address - Phone:252-535-4343
Practice Address - Fax:252-308-0977
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-24
Last Update Date:2011-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC35991174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8959536Medicaid
NC8959536Medicaid
NCB34781Medicare UPIN