Provider Demographics
NPI:1235310772
Name:RICHARDSON, EUGENE LEE (MD)
Entity Type:Individual
Prefix:
First Name:EUGENE
Middle Name:LEE
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 1:319 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MT
Mailing Address - Zip Code:59044-3031
Mailing Address - Country:US
Mailing Address - Phone:406-628-4955
Mailing Address - Fax:
Practice Address - Street 1:319 1ST AVE
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MT
Practice Address - Zip Code:59044-3031
Practice Address - Country:US
Practice Address - Phone:406-628-4955
Practice Address - Fax:406-628-4362
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-26
Last Update Date:2007-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT3193174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MTP00275410OtherRAILROAD MEDICARE