Provider Demographics
NPI:1205806361
Name:HOSTETTER, RICHARD B (MD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:B
Last Name:HOSTETTER
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 1:3702 NEW VISION DR BLDG B
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1703
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:207 N TOWNLINE RD STE 101
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:IN
Practice Address - Zip Code:46761-1325
Practice Address - Country:US
Practice Address - Phone:260-463-9316
Practice Address - Fax:260-463-9334
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2023-03-15
Deactivation Date:2023-01-18
Deactivation Code:
Reactivation Date:2023-03-15
Provider Licenses
StateLicense IDTaxonomies
IN01050312174400000X
IN01050312A2086X0206X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No174400000XOther Service ProvidersSpecialist
No2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200218420Medicaid
IN200218420Medicaid
IN188940BMedicare PIN