Provider Demographics
NPI:1689626392
Name:FAIOLA, RICHARD LOUIS (MD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:LOUIS
Last Name:FAIOLA
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 1:4001 HARRISON AVE NW
Mailing Address - Street 2:STE 101
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98502-5084
Mailing Address - Country:US
Mailing Address - Phone:360-704-2362
Mailing Address - Fax:360-350-1445
Practice Address - Street 1:4001 HARRISON AVE NW
Practice Address - Street 2:STE 101
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98502-5084
Practice Address - Country:US
Practice Address - Phone:360-704-2362
Practice Address - Fax:360-350-1445
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2014-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAXXXXXXXXXX207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA6622FAOtherRIDER
WA8576483Medicaid
WA0203077OtherLABOR AND INDUSTRY WA
WA8576483Medicaid
WAA08262Medicare PIN