Provider Demographics
NPI:1124047717
Name:RICHARD, JOHN W (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:W
Last Name:RICHARD
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 1:989 GOVERNORS LN STE 240
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40513-1175
Mailing Address - Country:US
Mailing Address - Phone:859-338-3958
Mailing Address - Fax:859-368-8135
Practice Address - Street 1:989 GOVERNORS LN STE 240
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40513-1175
Practice Address - Country:US
Practice Address - Phone:859-338-3958
Practice Address - Fax:859-368-8135
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2024-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY34055207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64340557Medicaid
KY64340557Medicaid
KYCB5773OtherRR MEDICARE GROUP
KY000000740304OtherANTHEM
KY4000501OtherMEDICARE LAB GROUP
KYK024820OtherMEDICARE PTAN
KY37903705OtherMEDICAID LAB GROUP
KY4000501OtherMEDICARE LAB GROUP
G44505Medicare UPIN
KY0091193Medicare ID - Type Unspecified