Provider Demographics
NPI:1225315385
Name:WILL RICHARDSON MD PA
Entity Type:Organization
Organization Name:WILL RICHARDSON MD PA
Other - Org Name:NATURA DERMATOLOGY & COSMETICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIE
Authorized Official - Middle Name:FORREST
Authorized Official - Last Name:RICHARDSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:954-537-4106
Mailing Address - Street 1:1120 BAYVIEW DR
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33304-2505
Mailing Address - Country:US
Mailing Address - Phone:954-537-4106
Mailing Address - Fax:
Practice Address - Street 1:6552 N STATE ROAD 7
Practice Address - Street 2:
Practice Address - City:COCONUT CREEK
Practice Address - State:FL
Practice Address - Zip Code:33073-3624
Practice Address - Country:US
Practice Address - Phone:954-537-4106
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-03
Last Update Date:2011-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9104609207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL30022ZMedicare PIN
FL102128Medicare UPIN