Provider Demographics
NPI:1295050342
Name:RICHARDSON, CORY GLEN (MD)
Entity type:Individual
Prefix:DR
First Name:CORY
Middle Name:GLEN
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 1:3318 N GRANDMILL LN
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-5689
Mailing Address - Country:US
Mailing Address - Phone:208-292-0445
Mailing Address - Fax:208-772-6514
Practice Address - Street 1:3318 N GRANDMILL LN
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-5689
Practice Address - Country:US
Practice Address - Phone:208-292-0445
Practice Address - Fax:208-772-6514
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-01
Last Update Date:2025-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-13357208600000X, 207RB0002X, 2086S0127X, 207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No207RB0002XAllopathic & Osteopathic PhysiciansInternal MedicineObesity MedicineGroup - Multi-Specialty
No2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma SurgeryGroup - Multi-Specialty
No207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1295050342Medicaid
ID1295050342Medicaid