Basic Information
| Provider Information | |||||||||
| NPI: | 1952341745 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LIVINGSTON | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | WEAVER | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2510 | ||||||||
| Address2: | |||||||||
| City: | EVANS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 308092510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7069228251 | ||||||||
| FaxNumber: | 7069226695 | ||||||||
| Practice Location | |||||||||
| Address1: | 363 N BELAIR RD | ||||||||
| Address2: | |||||||||
| City: | EVANS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30809 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7066507563 | ||||||||
| FaxNumber: | 7066500512 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2006 | ||||||||
| LastUpdateDate: | 08/12/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 08/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 040724 | GA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00905099A | 05 | GA | MEDICAID | G40724 | 05 | SC | MEDICAID | 336994 | 01 | GA | WELLCARE | OTHER | 10056154 | 01 | GA | AMERIGROUP | OTHER |