Provider Demographics
NPI:1467711754
Name:RICHMAN, JACK (MD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:
Last Name:RICHMAN
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 1:264 ELTON PARK ROAD
Mailing Address - Street 2:
Mailing Address - City:OAKVILLE
Mailing Address - State:ONTARIO
Mailing Address - Zip Code:L6J 4C1
Mailing Address - Country:CA
Mailing Address - Phone:905-849-1133
Mailing Address - Fax:905-845-0247
Practice Address - Street 1:264 ELTON PARK ROAD
Practice Address - Street 2:
Practice Address - City:OAKVILLE
Practice Address - State:ONTARIO
Practice Address - Zip Code:L6J 4C1
Practice Address - Country:CA
Practice Address - Phone:905-849-1133
Practice Address - Fax:905-845-0247
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-08
Last Update Date:2020-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT042-0007249207Q00000X
ZZ21406207Q00000X
VT042.0007249207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine