Provider Demographics
NPI:1972504348
Name:POLDER, RICHARD MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:MICHAEL
Last Name:POLDER
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 1:300 WEST WALLACE ST B2
Mailing Address - Street 2:
Mailing Address - City:FINDLAY
Mailing Address - State:OH
Mailing Address - Zip Code:45840
Mailing Address - Country:US
Mailing Address - Phone:419-422-3812
Mailing Address - Fax:419-422-4103
Practice Address - Street 1:300 WEST WALLACE ST B2
Practice Address - Street 2:
Practice Address - City:FINDLAY
Practice Address - State:OH
Practice Address - Zip Code:45840
Practice Address - Country:US
Practice Address - Phone:419-422-3812
Practice Address - Fax:419-422-4103
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH55168208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0741273Medicaid
E29558Medicare UPIN
OHPO 0634531Medicare ID - Type Unspecified