Provider Demographics
NPI:1205897956
Name:STORK, RICHARD JAMES (MD)
Entity type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:JAMES
Last Name:STORK
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:PO BOX 1267
Mailing Address - Street 2:
Mailing Address - City:MOUNT AIRY
Mailing Address - State:NC
Mailing Address - Zip Code:27030-1267
Mailing Address - Country:US
Mailing Address - Phone:336-786-4522
Mailing Address - Fax:336-789-3025
Practice Address - Street 1:110 DUTCHMAN CT
Practice Address - Street 2:
Practice Address - City:ELKIN
Practice Address - State:NC
Practice Address - Zip Code:28621-2237
Practice Address - Country:US
Practice Address - Phone:336-835-5330
Practice Address - Fax:336-835-5337
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2014-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000021916208VP0000X
GA047537208VP0000X
NC2007-00624208VP0000X
MO2008006962208VP0000X
NC2008006962208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000834666MMedicaid
NC018XVOtherBCBS OF NC
NC197955OtherMEDCOST
TN3893809Medicaid
AL009976335Medicaid
NC5906657Medicaid
MO113000001OtherMEDICARE PTAN
E89361Medicare UPIN
NC197955OtherMEDCOST
AL009976335Medicaid