Provider Demographics
NPI:1770667040
Name:RICH, MARK (MD/PHD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:RICH
Suffix:
Gender:M
Credentials:MD/PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1029 E HYDE RD
Mailing Address - Street 2:
Mailing Address - City:YELLOW SPRINGS
Mailing Address - State:OH
Mailing Address - Zip Code:45387-8789
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4100 W THIRD STREET
Practice Address - Street 2:DAYTON VA MEDICAL CENTER
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45428
Practice Address - Country:US
Practice Address - Phone:937-268-6511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0871972084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology