Provider Demographics
NPI:1528063203
Name:HART, RICHARD DAVIS (DO)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:DAVIS
Last Name:HART
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 1:15 BRENTWOOD TRACE
Mailing Address - Street 2:
Mailing Address - City:CLYDE
Mailing Address - State:NC
Mailing Address - Zip Code:28721-8021
Mailing Address - Country:US
Mailing Address - Phone:828-452-9700
Mailing Address - Fax:828-452-3701
Practice Address - Street 1:423 S SOUTH ST
Practice Address - Street 2:STE.101
Practice Address - City:MOUNT AIRY
Practice Address - State:NC
Practice Address - Zip Code:27030-4576
Practice Address - Country:US
Practice Address - Phone:336-786-5144
Practice Address - Fax:336-786-5146
Is Sole Proprietor?:No
Enumeration Date:2005-06-17
Last Update Date:2018-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200301239208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89136C8Medicaid
NCD93080Medicare UPIN
NC89136C8Medicaid
2401951AMedicare PIN