Provider Demographics
NPI:1942291711
Name:LODISE, RICHARD C (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:C
Last Name:LODISE
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 1:1780 W WESLEY RD NW
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30327-1910
Mailing Address - Country:US
Mailing Address - Phone:404-355-2130
Mailing Address - Fax:
Practice Address - Street 1:405 ARROWHEAD BLVD
Practice Address - Street 2:SUITE C
Practice Address - City:JONESBORO
Practice Address - State:GA
Practice Address - Zip Code:30236-1254
Practice Address - Country:US
Practice Address - Phone:770-478-9877
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2010-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA030699207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00447851AMedicaid
GA050030324OtherRAILROAD MEDICARE
GA050030324OtherRAILROAD MEDICARE
GA05BDBXSMedicare ID - Type UnspecifiedANESTHESIA