Healthcare Provider Details

I. General information

NPI: 1356313241
Provider Name (Legal Business Name): RICHARD CORDLE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/03/2006
Last Update Date: 11/02/2021
Certification Date: 11/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4348 ELECTRIC RD
ROANOKE VA
24018-0720
US

IV. Provider business mailing address

3027 CIRCLE DR SW
ROANOKE VA
24018-2107
US

V. Phone/Fax

Practice location:
  • Phone: 540-769-0976
  • Fax: 540-857-5391
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0101-233252
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License Number0101-233252
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: