Provider Demographics
NPI:1043328230
Name:RICHARDSON, WILLIE FORREST JR (MD)
Entity Type:Individual
Prefix:
First Name:WILLIE
Middle Name:FORREST
Last Name:RICHARDSON
Suffix:JR
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 1:1120 BAYVIEW DR
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33304-2505
Mailing Address - Country:US
Mailing Address - Phone:954-537-4106
Mailing Address - Fax:954-537-4186
Practice Address - Street 1:1120 BAYVIEW DR
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33304-2505
Practice Address - Country:US
Practice Address - Phone:954-537-4106
Practice Address - Fax:954-537-4186
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-28
Last Update Date:2011-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME94167207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL30022ZMedicare ID - Type Unspecified
I02128Medicare UPIN