Provider Demographics
NPI:1275979361
Name:RICHARDSON, KATHLEEN (MD)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4111 1ST AVE
Mailing Address - Street 2:STE 3
Mailing Address - City:NITRO
Mailing Address - State:WV
Mailing Address - Zip Code:25143-1345
Mailing Address - Country:US
Mailing Address - Phone:304-285-7200
Mailing Address - Fax:
Practice Address - Street 1:39 KENT RD STE 2
Practice Address - Street 2:
Practice Address - City:TIFTON
Practice Address - State:GA
Practice Address - Zip Code:31794-1697
Practice Address - Country:US
Practice Address - Phone:229-388-9393
Practice Address - Fax:229-388-9855
Is Sole Proprietor?:No
Enumeration Date:2013-05-15
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV26527207P00000X, 390200000X
GA84465207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program