Provider Demographics
NPI:1851495568
Name:MIMS, RICHARD CALVIN JR (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:CALVIN
Last Name:MIMS
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 73709
Mailing Address - Street 2:
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30271-3709
Mailing Address - Country:US
Mailing Address - Phone:770-251-2060
Mailing Address - Fax:678-854-9235
Practice Address - Street 1:80 NEWNAN STATION DRIVE, SUITE A
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30265
Practice Address - Country:US
Practice Address - Phone:770-251-2060
Practice Address - Fax:678-854-9235
Is Sole Proprietor?:No
Enumeration Date:2006-09-12
Last Update Date:2015-04-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA048804207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
05BDJTHMedicare PIN
B91859Medicare UPIN