Healthcare Provider Details

I. General information

NPI: 1578191722
Provider Name (Legal Business Name): RICHARD GROVE PARDO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2020
Last Update Date: 07/30/2024
Certification Date: 07/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1906 BRAEBURN DR
SALEM VA
24153-7304
US

IV. Provider business mailing address

1906 BRAEBURN DR
SALEM VA
24153-7304
US

V. Phone/Fax

Practice location:
  • Phone: 540-444-0460
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number72565
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: