Provider Demographics
NPI:1215222013
Name:RICHARDSON, BENJAMIN RUSSELL (DO)
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:RUSSELL
Last Name:RICHARDSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5171 CUB LAKE RD STE 210
Mailing Address - Street 2:
Mailing Address - City:SHOW LOW
Mailing Address - State:AZ
Mailing Address - Zip Code:85901-7888
Mailing Address - Country:US
Mailing Address - Phone:928-537-0635
Mailing Address - Fax:928-532-8957
Practice Address - Street 1:5171 CUB LAKE RD STE B210
Practice Address - Street 2:
Practice Address - City:SHOW LOW
Practice Address - State:AZ
Practice Address - Zip Code:85901-7866
Practice Address - Country:US
Practice Address - Phone:928-537-0635
Practice Address - Fax:928-532-8957
Is Sole Proprietor?:No
Enumeration Date:2011-06-09
Last Update Date:2017-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ006656207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ022296Medicaid
AZZ183792Medicare PIN