Provider Demographics
NPI:1942624192
Name:MAMELOK, RICHARD DAVID (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:DAVID
Last Name:MAMELOK
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 1:364 CHURCHILL AVE
Mailing Address - Street 2:
Mailing Address - City:PALO ALTO
Mailing Address - State:CA
Mailing Address - Zip Code:94301-3601
Mailing Address - Country:US
Mailing Address - Phone:650-924-0347
Mailing Address - Fax:
Practice Address - Street 1:364 CHURCHILL AVE
Practice Address - Street 2:
Practice Address - City:PALO ALTO
Practice Address - State:CA
Practice Address - Zip Code:94301-3601
Practice Address - Country:US
Practice Address - Phone:650-924-0347
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-08
Last Update Date:2014-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG33270207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG33270OtherTHE MEDICAL BOARD OF CALIFORNIA