Provider Demographics
NPI:1093815722
Name:RICHARDSON, CONNIE WALKER (MD)
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:WALKER
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:208 PIERSON AVENUE
Mailing Address - Street 2:BIBB MEDICAL CENTER
Mailing Address - City:CENTREVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35034
Mailing Address - Country:US
Mailing Address - Phone:205-926-3284
Mailing Address - Fax:205-926-4275
Practice Address - Street 1:208 PIERSON AVE
Practice Address - Street 2:
Practice Address - City:CENTREVILLE
Practice Address - State:AL
Practice Address - Zip Code:35042-2918
Practice Address - Country:US
Practice Address - Phone:205-926-3284
Practice Address - Fax:205-926-4275
Is Sole Proprietor?:No
Enumeration Date:2006-09-23
Last Update Date:2017-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME96736207Q00000X
AL21418207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL276849600Medicaid
FL276849600Medicaid
FLAB479XMedicare Oscar/Certification