Provider Demographics
NPI:1326276858
Name:RICHARDSON, TIMOTHY GERARD
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:GERARD
Last Name:RICHARDSON
Suffix:
Gender:M
Credentials:
Other - Prefix:DR
Other - First Name:TIMOTHY
Other - Middle Name:GERARD
Other - Last Name:RICHARDSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DC
Mailing Address - Street 1:11348 TARA BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:GA
Mailing Address - Zip Code:30228-6277
Mailing Address - Country:US
Mailing Address - Phone:404-606-0712
Mailing Address - Fax:
Practice Address - Street 1:11348 TARA BLVD STE 100
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:GA
Practice Address - Zip Code:30228-6277
Practice Address - Country:US
Practice Address - Phone:404-606-0712
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-23
Last Update Date:2009-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA008459111NI0013X, 111NN0400X, 111NS0005X, 111NX0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NX0800XChiropractic ProvidersChiropractorOrthopedic
No111NI0013XChiropractic ProvidersChiropractorIndependent Medical Examiner
No111NN0400XChiropractic ProvidersChiropractorNeurology
No111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA008459Medicaid