Provider Demographics
NPI:1700054178
Name:GRODIN, RICHARD WARREN (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:WARREN
Last Name:GRODIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1568 VICTORIA ISLE WAY
Mailing Address - Street 2:
Mailing Address - City:WESTON
Mailing Address - State:FL
Mailing Address - Zip Code:33327-1315
Mailing Address - Country:US
Mailing Address - Phone:954-650-5769
Mailing Address - Fax:
Practice Address - Street 1:365 STIRRUP KEY BLVD
Practice Address - Street 2:
Practice Address - City:MARATHON
Practice Address - State:FL
Practice Address - Zip Code:33050-2943
Practice Address - Country:US
Practice Address - Phone:954-363-1011
Practice Address - Fax:561-807-7836
Is Sole Proprietor?:No
Enumeration Date:2008-02-19
Last Update Date:2013-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME26691207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL93294OtherBLUE CROSS BLUE SHIELD OF FLORIDA
FL281015800Medicaid
FL33090Medicare PIN
FL281015800Medicaid
FLD60416Medicare UPIN