Provider Demographics
NPI:1962439109
Name:RICHARD, ETHAN CHRISTIAN (DO)
Entity type:Individual
Prefix:DR
First Name:ETHAN
Middle Name:CHRISTIAN
Last Name:RICHARD
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10840 VALLEY HILL RD
Mailing Address - Street 2:
Mailing Address - City:FORT MILL
Mailing Address - State:SC
Mailing Address - Zip Code:29707-7452
Mailing Address - Country:US
Mailing Address - Phone:913-291-7173
Mailing Address - Fax:
Practice Address - Street 1:885 GOLD HILL RD STE 506
Practice Address - Street 2:
Practice Address - City:FORT MILL
Practice Address - State:SC
Practice Address - Zip Code:29708-7946
Practice Address - Country:US
Practice Address - Phone:804-869-0341
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2024-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC82176207Q00000X
MO2006025644207Q00000X
NC2019-01089207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2006025644OtherLICENSE
MOMA1297008OtherMEDICARE