Provider Demographics
NPI:1588672067
Name:RICHARDSON, REVA A (MD)
Entity Type:Individual
Prefix:
First Name:REVA
Middle Name:A
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 307266
Mailing Address - Street 2:
Mailing Address - City:ST THOMAS
Mailing Address - State:VI
Mailing Address - Zip Code:00803-7266
Mailing Address - Country:US
Mailing Address - Phone:340-776-8112
Mailing Address - Fax:340-776-8113
Practice Address - Street 1:9149 ESTATE THOMAS
Practice Address - Street 2:PARAGON MEDICAL BUILDING, SUITE 301
Practice Address - City:ST THOMAS
Practice Address - State:VI
Practice Address - Zip Code:00802-2687
Practice Address - Country:US
Practice Address - Phone:340-776-8112
Practice Address - Fax:340-776-8113
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-03
Last Update Date:2015-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VI1278207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VII-12936Medicare UPIN
VI0022729Medicare ID - Type Unspecified