Provider Demographics
NPI:1629030838
Name:RICHARDSON, STEVEN G (MD)
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:G
Last Name:RICHARDSON
Suffix:
Gender:M
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 35380
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89133-5380
Mailing Address - Country:US
Mailing Address - Phone:801-316-9620
Mailing Address - Fax:
Practice Address - Street 1:1403 E SEGO LILY DR
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84092-4350
Practice Address - Country:US
Practice Address - Phone:801-316-9620
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-04
Last Update Date:2021-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11809415-1205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0104083OtherUHC
OHP00013823OtherRRM
OH000000286657OtherBCBS
OH2172830Medicaid
OH141867207026OtherCARESOURCE
OH141867207026OtherCARESOURCE
OHP00013823OtherRRM