Provider Demographics
NPI:1073670758
Name:RICHARDSON, DANIEL QUITMAN (MD)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:QUITMAN
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 6066
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39506-6066
Mailing Address - Country:US
Mailing Address - Phone:228-392-4454
Mailing Address - Fax:228-392-4533
Practice Address - Street 1:1720A MEDICAL PARK DR
Practice Address - Street 2:STE 140
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39532-2129
Practice Address - Country:US
Practice Address - Phone:228-392-4454
Practice Address - Fax:228-392-4533
Is Sole Proprietor?:No
Enumeration Date:2007-01-02
Last Update Date:2016-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS11075208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
D80519Medicare UPIN
240000022Medicare ID - Type Unspecified