Provider Demographics
NPI:1528174869
Name:HENRY J RICHTER MD PA
Entity type:Organization
Organization Name:HENRY J RICHTER MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:HENRY
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:RICHTER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-735-0068
Mailing Address - Street 1:PO BOX 1448
Mailing Address - Street 2:
Mailing Address - City:EUSTIS
Mailing Address - State:FL
Mailing Address - Zip Code:32727-1448
Mailing Address - Country:US
Mailing Address - Phone:352-735-0068
Mailing Address - Fax:352-735-0305
Practice Address - Street 1:1502 N DONNELLY ST
Practice Address - Street 2:SUITE 110
Practice Address - City:MT DORA
Practice Address - State:FL
Practice Address - Zip Code:32757-2846
Practice Address - Country:US
Practice Address - Phone:352-735-0068
Practice Address - Fax:352-735-0305
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-21
Last Update Date:2009-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME37512207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL59906OtherBCBS
FL066885100Medicaid
FL59906BMedicare ID - Type Unspecified
FL066885100Medicaid