Provider Demographics
NPI:1659368371
Name:RICHARDSON, AUGUSTUS CULLEN III (MD)
Entity Type:Individual
Prefix:
First Name:AUGUSTUS
Middle Name:CULLEN
Last Name:RICHARDSON
Suffix:III
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 1:605 N WESTOVER BLVD
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31707-2188
Mailing Address - Country:US
Mailing Address - Phone:229-434-4200
Mailing Address - Fax:229-434-4208
Practice Address - Street 1:605 N WESTOVER BLVD
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31707-2188
Practice Address - Country:US
Practice Address - Phone:229-434-4200
Practice Address - Fax:229-434-4208
Is Sole Proprietor?:No
Enumeration Date:2005-09-29
Last Update Date:2016-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA022464208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00300616BMedicaid
GAD42085Medicare UPIN
GA00300616BMedicaid