Provider Demographics
NPI:1538141171
Name:RICHARDSON, JUDY (MD)
Entity Type:Individual
Prefix:
First Name:JUDY
Middle Name:
Last Name:RICHARDSON
Suffix:
Gender:F
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:PO BOX 1520
Mailing Address - Street 2:
Mailing Address - City:THE DALLES
Mailing Address - State:OR
Mailing Address - Zip Code:97058-3390
Mailing Address - Country:US
Mailing Address - Phone:541-296-7677
Mailing Address - Fax:541-296-7206
Practice Address - Street 1:1935 E 19TH ST
Practice Address - Street 2:
Practice Address - City:THE DALLES
Practice Address - State:OR
Practice Address - Zip Code:97058-3390
Practice Address - Country:US
Practice Address - Phone:541-296-7677
Practice Address - Fax:541-296-7206
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2011-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD25035207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR022729Medicaid
OR500632165Medicaid
H80688Medicare UPIN
OR383994Medicare Oscar/Certification
OR383996Medicare Oscar/Certification
OR136957Medicare PIN
ORR0000WFBCSMedicare PIN
OR022729Medicaid
OR388506Medicare Oscar/Certification