Provider Demographics
NPI:1083837975
Name:JADICK, RICHARD HARRIS (DO)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:HARRIS
Last Name:JADICK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1555 DOCTORS DR STE 101
Mailing Address - Street 2:
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30240-4132
Mailing Address - Country:US
Mailing Address - Phone:706-803-7540
Mailing Address - Fax:706-803-8816
Practice Address - Street 1:1555 DOCTORS DR STE 101
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30240-4132
Practice Address - Country:US
Practice Address - Phone:706-803-7540
Practice Address - Fax:706-803-8816
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2024-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA069823208800000X
VT032.0091550208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL148SVOtherBLUE CROSS BLUE SHIELD OF FLORIDA
FL002330600Medicaid
VT003097701OtherMEDICARE PIN LINKED TO VN3891
FLDJ355ZMedicare PIN
VT1021261Medicaid
VT032.0091550OtherLICENSE