Basic Information
Provider Information | |||||||||
NPI: | 1700978038 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CRETELLA | ||||||||
FirstName: | RICHARD | ||||||||
MiddleName: | J. | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 310 MICKELSON LN | ||||||||
Address2: |   | ||||||||
City: | GEORGETOWN | ||||||||
State: | TX | ||||||||
PostalCode: | 786280913 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: |   | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2400 ROUND ROCK AVE | ||||||||
Address2: |   | ||||||||
City: | ROUND ROCK | ||||||||
State: | TX | ||||||||
PostalCode: | 786814004 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5123411000 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/28/2006 | ||||||||
LastUpdateDate: | 05/24/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207PE0004X | L2200 | TX | N |   | Allopathic & Osteopathic Physicians | Emergency Medicine | Emergency Medical Services | 207P00000X | L2200 | TX | Y |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 166957402 | 05 | TX |   | MEDICAID | 8B8464 | 01 | TX | BC/BS OF TEXAS | OTHER | 166957401 | 05 | TX |   | MEDICAID |