Provider Demographics
NPI:1750380259
Name:HENTHORN, RICHARD W (MD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:W
Last Name:HENTHORN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3000 MACK RD
Mailing Address - Street 2:STE 100
Mailing Address - City:FAIRFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45014-5335
Mailing Address - Country:US
Mailing Address - Phone:513-751-4222
Mailing Address - Fax:513-751-4353
Practice Address - Street 1:3000 MACK RD
Practice Address - Street 2:STE 100
Practice Address - City:FAIRFIELD
Practice Address - State:OH
Practice Address - Zip Code:45014-5335
Practice Address - Country:US
Practice Address - Phone:513-751-4222
Practice Address - Fax:513-751-4353
Is Sole Proprietor?:No
Enumeration Date:2005-07-18
Last Update Date:2015-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.043055207RC0000X, 207RC0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac Electrophysiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0673169Medicaid
IN100346000Medicaid
KY64864150Medicaid
OH0595459Medicare PIN
A16814Medicare UPIN
KY64864150Medicaid