1609803881 NPI number — DR. RANDOLPH MACON RICHARDSON IV DMD MD

Table of content: DR. RANDOLPH MACON RICHARDSON IV DMD MD (NPI 1609803881)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609803881 NPI number — DR. RANDOLPH MACON RICHARDSON IV DMD MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RICHARDSON
Provider First Name:
RANDOLPH
Provider Middle Name:
MACON
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
IV
Provider Credential Text:
DMD MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1609803881
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 07352
Provider Second Line Business Mailing Address:
6120 WINKLER RD STE F
Provider Business Mailing Address City Name:
FORT MYERS
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33919
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
239-437-1500
Provider Business Mailing Address Fax Number:
239-437-1560

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6120 WINKLER RD
Provider Second Line Business Practice Location Address:
STE F
Provider Business Practice Location Address City Name:
FORT MYERS
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33919
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
239-437-1500
Provider Business Practice Location Address Fax Number:
239-437-1560
Provider Enumeration Date:
06/26/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
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Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 204E00000X , with the licence number:  DN0014165 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)