Provider Demographics
NPI:1558475814
Name:RICHARDSON-TE, CAROL (MD)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:
Last Name:RICHARDSON-TE
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 1:1245 WILSHIRE BLVD
Mailing Address - Street 2:STE 630
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90017-4888
Mailing Address - Country:US
Mailing Address - Phone:213-977-0511
Mailing Address - Fax:213-481-2763
Practice Address - Street 1:1245 WILSHIRE BLVD
Practice Address - Street 2:STE 630
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90017-4888
Practice Address - Country:US
Practice Address - Phone:213-977-0511
Practice Address - Fax:213-481-2763
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-17
Last Update Date:2017-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA89382207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A893820Medicaid
CA00A893820Medicaid
CAI60133Medicare UPIN