Provider Demographics
NPI:1144229253
Name:RICHARDSON, HEATHER (MD)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:
Other - Last Name:RICHARDSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:436 N BEDFORD DR
Mailing Address - Street 2:SUITE 105
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90210-4310
Mailing Address - Country:US
Mailing Address - Phone:310-278-8590
Mailing Address - Fax:424-202-3759
Practice Address - Street 1:436 N BEDFORD DR
Practice Address - Street 2:SUITE 105
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90210-4310
Practice Address - Country:US
Practice Address - Phone:310-278-8590
Practice Address - Fax:424-202-3759
Is Sole Proprietor?:No
Enumeration Date:2005-07-20
Last Update Date:2017-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA053395208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA727464006AMedicaid
GA727464006AMedicaid
02BBGNRMedicare ID - Type Unspecified