Provider Demographics
NPI:1124056494
Name:FAWCETT, RICHARD W (MD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:W
Last Name:FAWCETT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:813 SW HIGHLAND AVE
Mailing Address - Street 2:STE 101
Mailing Address - City:REDMOND
Mailing Address - State:OR
Mailing Address - Zip Code:97756-3103
Mailing Address - Country:US
Mailing Address - Phone:541-548-3153
Mailing Address - Fax:541-548-3376
Practice Address - Street 1:333 NW LARCH AVE
Practice Address - Street 2:STE 2
Practice Address - City:REDMOND
Practice Address - State:OR
Practice Address - Zip Code:97756-1186
Practice Address - Country:US
Practice Address - Phone:541-548-3153
Practice Address - Fax:541-548-3376
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2019-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD233472083P0901X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR287298Medicaid
OR1124056494OtherNPI
OR287298Medicaid
ORG85625Medicare UPIN