Provider Demographics
NPI:1073051892
Name:RICHARDSON, CAROL
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:
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 4361
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MS
Mailing Address - Zip Code:39441-4361
Mailing Address - Country:US
Mailing Address - Phone:601-399-1945
Mailing Address - Fax:
Practice Address - Street 1:103 S 12TH AVE
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MS
Practice Address - Zip Code:39440-4322
Practice Address - Country:US
Practice Address - Phone:601-399-1970
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-01
Last Update Date:2017-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301073267207Q00000X
MS25238207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS03937772Medicaid