Provider Demographics
NPI:1346398419
Name:RICHARDSON, GLENDA JOHNSON (MD)
Entity Type:Individual
Prefix:
First Name:GLENDA
Middle Name:JOHNSON
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 1:43 ELWOOD DR.
Mailing Address - Street 2:
Mailing Address - City:DESTREHAN
Mailing Address - State:LA
Mailing Address - Zip Code:70047-3703
Mailing Address - Country:US
Mailing Address - Phone:504-466-1251
Mailing Address - Fax:504-466-2014
Practice Address - Street 1:2100 3RD STREET
Practice Address - Street 2:SUITE 6
Practice Address - City:KENNER
Practice Address - State:LA
Practice Address - Zip Code:70062-7600
Practice Address - Country:US
Practice Address - Phone:566-125-1044
Practice Address - Fax:504-466-2014
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA014496208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1301922Medicaid
LAE74040Medicare UPIN