Provider Demographics
NPI:1124179445
Name:RICHARDSON, JUSTIN (MD)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
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 1:21 W 12TH ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10011-8549
Mailing Address - Country:US
Mailing Address - Phone:212-647-1667
Mailing Address - Fax:
Practice Address - Street 1:21 W 12TH ST
Practice Address - Street 2:SUITE A
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10011-8549
Practice Address - Country:US
Practice Address - Phone:212-647-1667
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1950822084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYF56925Medicare UPIN