Provider Demographics
NPI:1538163985
Name:SHERRY, RICHARD G (MD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:G
Last Name:SHERRY
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:PO BOX 493
Mailing Address - Street 2:
Mailing Address - City:SACKETS HARBOR
Mailing Address - State:NY
Mailing Address - Zip Code:13685-0493
Mailing Address - Country:US
Mailing Address - Phone:540-597-8469
Mailing Address - Fax:
Practice Address - Street 1:1340 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-4541
Practice Address - Country:US
Practice Address - Phone:315-782-9003
Practice Address - Fax:315-782-9010
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-13
Last Update Date:2016-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY376752085N0700X, 2085R0202X
VA0101-2425292085R0202X
NY1266872085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200427120Medicaid
WV3810010288Medicaid
KY64057748Medicaid
VA015208R19Medicare PIN
KYE34077Medicare UPIN
KY0276163Medicare ID - Type Unspecified
KY0709843Medicare ID - Type Unspecified
VAP00439898Medicare PIN