Provider Demographics
NPI:1164446548
Name:RICHARDSON, TIMOTHY (MD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
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:PO BOX 1486
Mailing Address - Street 2:
Mailing Address - City:RANCHO MIRAGE
Mailing Address - State:CA
Mailing Address - Zip Code:92270-1049
Mailing Address - Country:US
Mailing Address - Phone:760-341-1999
Mailing Address - Fax:760-341-1997
Practice Address - Street 1:36867 COOK ST
Practice Address - Street 2:SUITE 101
Practice Address - City:PALM DESERT
Practice Address - State:CA
Practice Address - Zip Code:92211-6064
Practice Address - Country:US
Practice Address - Phone:760-341-1999
Practice Address - Fax:760-341-1997
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2022-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG53073207N00000X, 207NS0135X, 207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE24193Medicare UPIN
CA00G530730Medicare ID - Type Unspecified