Provider Demographics
NPI:1356480354
Name:RICHARDSON, GLADYS (MD)
Entity Type:Individual
Prefix:DR
First Name:GLADYS
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 1:106 BLANCA AVE
Mailing Address - Street 2:SLV REGIONAL MEDICAL CENTER
Mailing Address - City:ALAMOSA
Mailing Address - State:CO
Mailing Address - Zip Code:81101-2340
Mailing Address - Country:US
Mailing Address - Phone:719-589-8008
Mailing Address - Fax:719-589-8012
Practice Address - Street 1:2115 STUART AVE
Practice Address - Street 2:SLV REGIONAL MEDICAL CENTER
Practice Address - City:ALAMOSA
Practice Address - State:CO
Practice Address - Zip Code:81101-2269
Practice Address - Country:US
Practice Address - Phone:719-589-8008
Practice Address - Fax:719-589-8012
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2009-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2005-04272084P0800X
CO310212084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1310218Medicaid
CO1310218Medicaid