Provider Demographics
NPI:1013900505
Name:PRETORIUS, RICHARD (MD, MPH)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:PRETORIUS
Suffix:
Gender:M
Credentials:MD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:845 ROUTES 5 & 20
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:NY
Mailing Address - Zip Code:14081-9706
Mailing Address - Country:US
Mailing Address - Phone:716-951-7273
Mailing Address - Fax:
Practice Address - Street 1:845 ROUTES 5 & 20
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:NY
Practice Address - Zip Code:14081-9706
Practice Address - Country:US
Practice Address - Phone:716-951-7273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-30
Last Update Date:2015-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY46970207P00000X
OH35-057683207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02560378Medicaid
OH3120563Medicaid
KY7100319390Medicaid
OH4312641Medicare PIN
NYRA2812Medicare ID - Type Unspecified
OH3120563Medicaid