Provider Demographics
NPI:1073606984
Name:RICHARDSON, TRAVIS A (MD)
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:A
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 1:1111 RONALD REAGAN PKWY STE C1400
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:IN
Mailing Address - Zip Code:46123-7085
Mailing Address - Country:US
Mailing Address - Phone:317-217-2777
Mailing Address - Fax:
Practice Address - Street 1:1111 RONALD REAGAN PKWY STE 1400
Practice Address - Street 2:
Practice Address - City:AVON
Practice Address - State:IN
Practice Address - Zip Code:46123-7085
Practice Address - Country:US
Practice Address - Phone:317-217-2777
Practice Address - Fax:317-217-2775
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01049572207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200525560Medicaid
IN228250DMedicare PIN
IN200525560Medicaid
P00373708Medicare PIN
INI30355Medicare UPIN