Provider Demographics
NPI:1568552719
Name:RICHARDSON, DEREK PROCTOR (MD)
Entity Type:Individual
Prefix:DR
First Name:DEREK
Middle Name:PROCTOR
Last Name:RICHARDSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:FOUR IRONGATE CENTER
Mailing Address - Street 2:
Mailing Address - City:GLENS FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:12801
Mailing Address - Country:US
Mailing Address - Phone:518-798-1778
Mailing Address - Fax:518-798-1846
Practice Address - Street 1:FOUR IRONGATE CENTER
Practice Address - Street 2:
Practice Address - City:GLENS FALLS
Practice Address - State:NY
Practice Address - Zip Code:12801
Practice Address - Country:US
Practice Address - Phone:518-798-1778
Practice Address - Fax:518-798-1846
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2022-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY114475207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY000407083001OtherBLUE SHIELD
NY040426007626OtherFIDELIS
NY07121OtherMVP HEALTH PLAN
NY10001709OtherCDPHP
141622071OtherTAX ID #
NY48F2111OtherBLUE CROSS
NY00352149Medicaid
NY000407083001OtherBLUE SHIELD
NY00352149Medicaid