Basic Information
| Provider Information | |||||||||
| NPI: | 1750455788 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HARTMANN | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 201 N CLYDE MORRIS BLVD STE 200 | ||||||||
| Address2: | HALIFAX FAMILY HEALTH CENTER | ||||||||
| City: | DAYTONA BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321142765 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3862544165 | ||||||||
| FaxNumber: | 3862584891 | ||||||||
| Practice Location | |||||||||
| Address1: | 201 N CLYDE MORRIS BLVD STE 200 | ||||||||
| Address2: | HALIFAX FAMILY HEALTH CENTER | ||||||||
| City: | DAYTONA BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321142765 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3862544165 | ||||||||
| FaxNumber: | 3862584891 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/20/2006 | ||||||||
| LastUpdateDate: | 08/10/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | ME40753 | FL | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 067989500 | 05 | FL | MEDICAID |