Provider Demographics
NPI:1417934902
Name:RICHARDS, ROSELAVENDER A (MD)
Entity Type:Individual
Prefix:
First Name:ROSELAVENDER
Middle Name:A
Last Name:RICHARDS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ROSELAVENDER
Other - Middle Name:A
Other - Last Name:RICHARDS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD INC
Mailing Address - Street 1:3420 E SHEA BLVD STE 200266
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85028-3345
Mailing Address - Country:US
Mailing Address - Phone:480-977-6000
Mailing Address - Fax:248-269-0631
Practice Address - Street 1:3420 EAST SHEA BLVD
Practice Address - Street 2:STE 200 OFFICE 266
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85028
Practice Address - Country:US
Practice Address - Phone:480-977-6000
Practice Address - Fax:248-269-0631
Is Sole Proprietor?:No
Enumeration Date:2005-12-27
Last Update Date:2019-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ23096207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAZ0702650OtherBC BS OF AZ
AZ318205Medicaid
AZAZ0702650OtherBC BS OF AZ
F43522Medicare UPIN