Provider Demographics
NPI:1457663163
Name:RICHARDSON, JUSTIN NICKLAUS (MD)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:NICKLAUS
Last Name:RICHARDSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4743 ARAPAHOE AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80303-1123
Mailing Address - Country:US
Mailing Address - Phone:303-443-2123
Mailing Address - Fax:303-443-9497
Practice Address - Street 1:4743 ARAPAHOE AVE STE 100
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80303-1123
Practice Address - Country:US
Practice Address - Phone:303-443-2123
Practice Address - Fax:303-443-9497
Is Sole Proprietor?:No
Enumeration Date:2010-07-10
Last Update Date:2020-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0053765208600000X
COCDRH.0053765208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
COP01401976OtherMEDICARE RAILROAD
CO365056YMMWMedicare PIN