Provider Demographics
NPI:1912941196
Name:GEORGE, RICHARD L (MD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:L
Last Name:GEORGE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11109 PARKVIEW PLAZA DR # 117
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11141 PARKVIEW PLAZA DR STE 305
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-1715
Practice Address - Country:US
Practice Address - Phone:260-266-8900
Practice Address - Fax:260-266-8935
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2024-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL22388208600000X
OH35.0940712086S0102X
IN01094175A2086S0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
No208600000XAllopathic & Osteopathic PhysiciansSurgery