Provider Demographics
NPI:1144230038
Name:RICHARDSON, JOHN DAVID (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:DAVID
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 1:439 N JACKSON ST STE D
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:39601-2912
Mailing Address - Country:US
Mailing Address - Phone:601-835-9499
Mailing Address - Fax:601-833-7808
Practice Address - Street 1:439 N JACKSON ST STE D
Practice Address - Street 2:
Practice Address - City:BROOKHAVEN
Practice Address - State:MS
Practice Address - Zip Code:39601-2912
Practice Address - Country:US
Practice Address - Phone:601-835-9499
Practice Address - Fax:601-833-7808
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2019-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS114112084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00119784Medicaid
MS00119784Medicaid
MS260000227Medicare ID - Type Unspecified