Provider Demographics
NPI:1427162221
Name:PIDALA, RICK PATRICK (DPM)
Entity type:Individual
Prefix:
First Name:RICK
Middle Name:PATRICK
Last Name:PIDALA
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:890 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:OH
Mailing Address - Zip Code:44146-3612
Mailing Address - Country:US
Mailing Address - Phone:440-439-8282
Mailing Address - Fax:440-439-7863
Practice Address - Street 1:890 BROADWAY
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:OH
Practice Address - Zip Code:44146-3612
Practice Address - Country:US
Practice Address - Phone:440-439-8282
Practice Address - Fax:440-439-7863
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-18
Last Update Date:2008-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36001964213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0444586Medicaid
OH0444586Medicaid
T80500Medicare UPIN
OH0487410001Medicare NSC