Provider Demographics
NPI:1922003086
Name:STORM, RICHARD MASON (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:MASON
Last Name:STORM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:622 N MADISON AVE
Mailing Address - Street 2:STE 5
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46142-4052
Mailing Address - Country:US
Mailing Address - Phone:317-743-8930
Mailing Address - Fax:317-743-8937
Practice Address - Street 1:622 N MADISON AVE
Practice Address - Street 2:STE 5
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46142-4052
Practice Address - Country:US
Practice Address - Phone:317-743-8930
Practice Address - Fax:317-743-8937
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-16
Last Update Date:2016-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01029002A207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN15D0352826OtherCLIA
IN15D0352826OtherCLIA
INB29479Medicare UPIN