Provider Demographics
NPI:1215193651
Name:RICHARDS, JOHN JACKSON (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:JACKSON
Last Name:RICHARDS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1005 HEALTH CENTER DR STE 201
Mailing Address - Street 2:
Mailing Address - City:MATTOON
Mailing Address - State:IL
Mailing Address - Zip Code:61938-4693
Mailing Address - Country:US
Mailing Address - Phone:217-238-6055
Mailing Address - Fax:217-258-2216
Practice Address - Street 1:890 E RIDGELAWN RD
Practice Address - Street 2:
Practice Address - City:MARTINSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62442-2551
Practice Address - Country:US
Practice Address - Phone:217-382-4191
Practice Address - Fax:217-382-4248
Is Sole Proprietor?:No
Enumeration Date:2008-08-05
Last Update Date:2019-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN11013443A207Q00000X
IL036-121753207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine