Provider Demographics
NPI:1629363072
Name:RICHARDSON, PHILLIP E (DPM)
Entity Type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:E
Last Name:RICHARDSON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7701 W ASPERA BLVD
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-7947
Mailing Address - Country:US
Mailing Address - Phone:623-248-2100
Mailing Address - Fax:
Practice Address - Street 1:7701 W ASPERA BLVD
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-7947
Practice Address - Country:US
Practice Address - Phone:623-248-2100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-14
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN07001258A213ES0103X
KY00497213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300004767Medicaid
AZ041394Medicaid
IN300004767Medicaid
AZZ190619Medicare PIN