Provider Demographics
NPI:1376586529
Name:RICHERT, EDWARD PAUL (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:PAUL
Last Name:RICHERT
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 1:710 E 5TH ST
Mailing Address - Street 2:
Mailing Address - City:ALTURAS
Mailing Address - State:CA
Mailing Address - Zip Code:96101-3506
Mailing Address - Country:US
Mailing Address - Phone:530-233-4680
Mailing Address - Fax:
Practice Address - Street 1:229 MCDOWELL ST
Practice Address - Street 2:
Practice Address - City:ALTURAS
Practice Address - State:CA
Practice Address - Zip Code:96101
Practice Address - Country:US
Practice Address - Phone:530-233-7052
Practice Address - Fax:530-233-4302
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG35911207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G359110Medicaid
CA00G359110Medicaid
00G359110Medicare ID - Type Unspecified