Provider Demographics
NPI:1710193073
Name:WARREN, RICHARD EUGENE II
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:EUGENE
Last Name:WARREN
Suffix:II
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:RICHARD
Other - Middle Name:EUGENE
Other - Last Name:WARREN
Other - Suffix:II
Other - Last Name Type:Professional Name
Other - Credentials:LAC MTOM
Mailing Address - Street 1:152 W COMMERCIAL ST
Mailing Address - Street 2:
Mailing Address - City:EAST ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14445-2150
Mailing Address - Country:US
Mailing Address - Phone:585-381-6490
Mailing Address - Fax:585-381-6188
Practice Address - Street 1:152 W COMMERCIAL ST
Practice Address - Street 2:
Practice Address - City:EAST ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14445-2150
Practice Address - Country:US
Practice Address - Phone:585-381-6490
Practice Address - Fax:585-381-6188
Is Sole Proprietor?:No
Enumeration Date:2007-05-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000829-1171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY7944323OtherAETNA CLAIM #