Provider Demographics
NPI:1407156193
Name:DEREK P RICHARDSON,MD,PC
Entity Type:Organization
Organization Name:DEREK P RICHARDSON,MD,PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:P
Authorized Official - Last Name:RICHARDSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:518-798-1778
Mailing Address - Street 1:4 IRONGATE CTR
Mailing Address - Street 2:
Mailing Address - City:GLENS FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:12801-3471
Mailing Address - Country:US
Mailing Address - Phone:518-798-1778
Mailing Address - Fax:518-798-1846
Practice Address - Street 1:4 IRONGATE CTR
Practice Address - Street 2:
Practice Address - City:GLENS FALLS
Practice Address - State:NY
Practice Address - Zip Code:12801-3471
Practice Address - Country:US
Practice Address - Phone:518-798-1778
Practice Address - Fax:518-798-1846
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-27
Last Update Date:2010-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY114475207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYB80085Medicare UPIN