Provider Demographics
NPI:1821045204
Name:MENDIETA, RICHARD J (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:J
Last Name:MENDIETA
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 1:90 JACKSON PIKE
Mailing Address - Street 2:
Mailing Address - City:GALLIPOLIS
Mailing Address - State:OH
Mailing Address - Zip Code:45631-1560
Mailing Address - Country:US
Mailing Address - Phone:740-441-1949
Mailing Address - Fax:740-446-5982
Practice Address - Street 1:100 JACKSON PIKE
Practice Address - Street 2:
Practice Address - City:GALLIPOLIS
Practice Address - State:OH
Practice Address - Zip Code:45631-1560
Practice Address - Country:US
Practice Address - Phone:740-446-5371
Practice Address - Fax:740-446-5711
Is Sole Proprietor?:No
Enumeration Date:2006-05-30
Last Update Date:2020-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV19317208000000X
OH35.072682208000000X
OH35-07-2682208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH310917085028OtherCARESOURCE MEDICAID
WV0111033000Medicaid
000000007410OtherANTHEM BCBS
OH000000181967OtherUNISON MEDICAID
OH2037718OtherMOLINA MEDICAID
370008914OtherRR MEDICARE
001714096OtherMOUNTAIN STATE BCBS
OH000000181967OtherUNISON MEDICAID
OH310917085028OtherCARESOURCE MEDICAID
G58283Medicare UPIN