Healthcare Provider Details

I. General information

NPI: 1316902984
Provider Name (Legal Business Name): RICHARD IRA LETVAK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2006
Last Update Date: 09/28/2021
Certification Date: 09/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

940 GOLF HOUSE ROAD COURT E
WHITSETT NC
27377
US

IV. Provider business mailing address

1200 N ELM ST
GREENSBORO NC
27401-1004
US

V. Phone/Fax

Practice location:
  • Phone: 336-449-9748
  • Fax:
Mailing address:
  • Phone: 336-832-7000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number9701033
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number9701033
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: