Provider Demographics
NPI:1962441881
Name:GERGOUDIS, RICHARD L (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:L
Last Name:GERGOUDIS
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 1:1800 GLENSIDE DR
Mailing Address - Street 2:SUITE 105
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23226-3769
Mailing Address - Country:US
Mailing Address - Phone:804-288-0399
Mailing Address - Fax:804-285-0088
Practice Address - Street 1:1800 GLENSIDE DR
Practice Address - Street 2:STE 110
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23226-3769
Practice Address - Country:US
Practice Address - Phone:804-288-1800
Practice Address - Fax:804-288-0515
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2011-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101043513207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA080182275OtherMEDICARE RAILROAD
VAP00703817OtherRR MEDICARE
VA141471OtherANTHEM
VA005635306Medicaid
VA141471OtherANTHEM
VA080007977Medicare PIN