Provider Demographics
NPI:1699778142
Name:STATESIR, RICHARD ALLEN (MD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:ALLEN
Last Name:STATESIR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:14701 DETROIT AVE
Mailing Address - Street 2:STE 280
Mailing Address - City:LAKEWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44107-4109
Mailing Address - Country:US
Mailing Address - Phone:216-228-9122
Mailing Address - Fax:216-221-9773
Practice Address - Street 1:14701 DETROIT AVE
Practice Address - Street 2:STE 280
Practice Address - City:LAKEWOOD
Practice Address - State:OH
Practice Address - Zip Code:44107-4109
Practice Address - Country:US
Practice Address - Phone:216-228-9122
Practice Address - Fax:216-221-9773
Is Sole Proprietor?:No
Enumeration Date:2005-05-28
Last Update Date:2012-02-02
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
OH35053677S207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0626273Medicaid
OH0626273Medicaid
0474400001Medicare NSC
OHA16444Medicare UPIN