Provider Demographics
NPI:1952380818
Name:SHATZ, RICHARD NELSON (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:NELSON
Last Name:SHATZ
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 1:1135 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62301-2809
Mailing Address - Country:US
Mailing Address - Phone:217-228-1312
Mailing Address - Fax:217-228-1316
Practice Address - Street 1:1135 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62301-2809
Practice Address - Country:US
Practice Address - Phone:217-228-1312
Practice Address - Fax:217-228-1316
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-10
Last Update Date:2011-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036107867208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036107867Medicaid
D91157Medicare UPIN
204121Medicare ID - Type Unspecified