Basic Information
| Provider Information | |||||||||
| NPI: | 1821045204 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MENDIETA | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | J. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 90 JACKSON PIKE | ||||||||
| Address2: | |||||||||
| City: | GALLIPOLIS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456311560 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7404411949 | ||||||||
| FaxNumber: | 7404465982 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 JACKSON PIKE | ||||||||
| Address2: | |||||||||
| City: | GALLIPOLIS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456311560 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7404465371 | ||||||||
| FaxNumber: | 7404465711 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/30/2006 | ||||||||
| LastUpdateDate: | 11/04/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/04/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 19317 | WV | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 35.072682 | OH | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 35-07-2682 | OH | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 310917085028 | 01 | OH | CARESOURCE MEDICAID | OTHER | 0111033000 | 05 | WV | MEDICAID | 000000007410 | 01 | ANTHEM BCBS | OTHER | 000000181967 | 01 | OH | UNISON MEDICAID | OTHER | 2037718 | 01 | OH | MOLINA MEDICAID | OTHER | 370008914 | 01 | RR MEDICARE | OTHER | 001714096 | 01 | MOUNTAIN STATE BCBS | OTHER |