Provider Demographics
NPI:1477594646
Name:RICHARDSON, MICHAEL DALE
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:DALE
Last Name:RICHARDSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 VITTORI CT
Mailing Address - Street 2:
Mailing Address - City:COLEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:96107-9403
Mailing Address - Country:US
Mailing Address - Phone:530-495-2557
Mailing Address - Fax:
Practice Address - Street 1:HC-83 BLDG 3005
Practice Address - Street 2:NAVAL HOSPITAL BRANCH CLINIC MCMWTC
Practice Address - City:BRIDGEPORT
Practice Address - State:CA
Practice Address - Zip Code:93517-0001
Practice Address - Country:US
Practice Address - Phone:760-932-1616
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman