Provider Demographics
NPI:1962428557
Name:SO, RICHARD (MD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:SO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20800 WESTGATE MALL
Mailing Address - Street 2:SUITE 400
Mailing Address - City:FAIRVIEW PARK
Mailing Address - State:OH
Mailing Address - Zip Code:44126-1323
Mailing Address - Country:US
Mailing Address - Phone:440-356-2272
Mailing Address - Fax:440-356-2299
Practice Address - Street 1:20800 WESTGATE MALL
Practice Address - Street 2:SUITE 400
Practice Address - City:FAIRVIEW PARK
Practice Address - State:OH
Practice Address - Zip Code:44126-1323
Practice Address - Country:US
Practice Address - Phone:440-356-2272
Practice Address - Fax:440-356-2299
Is Sole Proprietor?:No
Enumeration Date:2006-07-15
Last Update Date:2009-01-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OH35090551208000000X, 207RS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207RS0010XAllopathic & Osteopathic PhysiciansInternal MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000536776OtherANTHEM BC/BS
OH340714618243OtherCARESOURCE
OH2780745Medicaid
OH2780745Medicaid
OH7379611Medicare PIN