Provider Demographics
NPI:1699090936
Name:RICHARD A. STATESIR,MD INC.
Entity type:Organization
Organization Name:RICHARD A. STATESIR,MD INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:A
Authorized Official - Last Name:STATESIR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:216-228-9122
Mailing Address - Street 1:14701 DETROIT AVE
Mailing Address - Street 2:SUITE 280
Mailing Address - City:LAKEWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44107-4115
Mailing Address - Country:US
Mailing Address - Phone:216-228-9122
Mailing Address - Fax:
Practice Address - Street 1:14701 DETROIT AVE
Practice Address - Street 2:SUITE 280
Practice Address - City:LAKEWOOD
Practice Address - State:OH
Practice Address - Zip Code:44107-4115
Practice Address - Country:US
Practice Address - Phone:216-228-9122
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-30
Last Update Date:2012-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH053677207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0474400001Medicare NSC
RIO583192Medicare PIN