Basic Information
| Provider Information | |||||||||
| NPI: | 1528063203 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HART | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | DAVIS | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15 BRENTWOOD TRACE | ||||||||
| Address2: | |||||||||
| City: | CLYDE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287218021 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8284529700 | ||||||||
| FaxNumber: | 8284523701 | ||||||||
| Practice Location | |||||||||
| Address1: | 423 S SOUTH ST | ||||||||
| Address2: | STE.101 | ||||||||
| City: | MOUNT AIRY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 270304576 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367865144 | ||||||||
| FaxNumber: | 3367865146 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2005 | ||||||||
| LastUpdateDate: | 02/01/2018 | ||||||||
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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 | 208800000X | 200301239 | NC | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 89136C8 | 05 | NC | MEDICAID |