Provider Demographics
NPI:1851350631
Name:MIOTKE, RICHARD JOSEPH (PTA)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:JOSEPH
Last Name:MIOTKE
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5545
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47903-5545
Mailing Address - Country:US
Mailing Address - Phone:765-448-8000
Mailing Address - Fax:765-448-8335
Practice Address - Street 1:2601 FERRY ST
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47904-3061
Practice Address - Country:US
Practice Address - Phone:765-448-8000
Practice Address - Fax:765-448-8335
Is Sole Proprietor?:No
Enumeration Date:2006-03-21
Last Update Date:2010-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06002632A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000188968OtherANTHEM PROVIDER NUMBER
IN100099590Medicaid