Provider Demographics
NPI:1689610834
Name:HADDOCK, RICHARD AUSTIN IV (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:AUSTIN
Last Name:HADDOCK
Suffix:IV
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 1:503 4TH ST
Mailing Address - Street 2:
Mailing Address - City:LA GRANDE
Mailing Address - State:OR
Mailing Address - Zip Code:97850-1905
Mailing Address - Country:US
Mailing Address - Phone:541-963-2886
Mailing Address - Fax:
Practice Address - Street 1:503 4TH ST
Practice Address - Street 2:
Practice Address - City:LA GRANDE
Practice Address - State:OR
Practice Address - Zip Code:97850-1905
Practice Address - Country:US
Practice Address - Phone:541-963-2886
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD08569208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR-083501Medicaid
ORC92786Medicare UPIN
ORR-0000BHDGNMedicare ID - Type Unspecified