Provider Demographics
NPI:1023000775
Name:RICHARDSON, NICOLE R (DO)
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:R
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2101 E JEFFERSON ST
Mailing Address - Street 2:KAISER PERMANENTE MEDICARE ENROLLMENT
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20852-4908
Mailing Address - Country:US
Mailing Address - Phone:301-816-2424
Mailing Address - Fax:
Practice Address - Street 1:2007 2ND ST NW
Practice Address - Street 2:KAISER PERMANENTE CAPITOL HILL MEDICAL CENTER
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20001-1626
Practice Address - Country:US
Practice Address - Phone:202-346-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-18
Last Update Date:2012-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDH0060781207R00000X
DCDO034181207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDH99740Medicare UPIN