Provider Demographics
NPI:1063468205
Name:RICHARDSON, GEORGE WILLIAM (MD)
Entity Type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:WILLIAM
Last Name:RICHARDSON
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 217
Mailing Address - Street 2:
Mailing Address - City:CLARINDA
Mailing Address - State:IA
Mailing Address - Zip Code:51632-2625
Mailing Address - Country:US
Mailing Address - Phone:712-542-2176
Mailing Address - Fax:712-542-8311
Practice Address - Street 1:220 ESSIE DAVISON DR
Practice Address - Street 2:
Practice Address - City:CLARINDA
Practice Address - State:IA
Practice Address - Zip Code:51632-2915
Practice Address - Country:US
Practice Address - Phone:712-542-8330
Practice Address - Fax:712-542-3373
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2012-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA19509207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA2149526Medicaid
IAA03883Medicare UPIN
IAI10723Medicare ID - Type Unspecified