Provider Demographics
NPI:1942490016
Name:PHELPS, RICHARD CANNON (DO)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:CANNON
Last Name:PHELPS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7301 W PALMETTO PARK RD STE 204A
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33433-3456
Mailing Address - Country:US
Mailing Address - Phone:561-342-8822
Mailing Address - Fax:561-342-8985
Practice Address - Street 1:9980 CENTRAL PARK BLVD N STE 210
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33428-1703
Practice Address - Country:US
Practice Address - Phone:561-342-8822
Practice Address - Fax:561-342-8985
Is Sole Proprietor?:No
Enumeration Date:2007-07-25
Last Update Date:2020-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS128962084P0800X
CT89717390200000X, 2084P0015X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2084P0015XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychosomatic Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC327877Medicaid
SC327877Medicaid