Provider Demographics
NPI:1669473286
Name:RICHARDSON, THOMAS L (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:L
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 1:301 E 2ND ST
Mailing Address - Street 2:
Mailing Address - City:RICHLAND CENTER
Mailing Address - State:WI
Mailing Address - Zip Code:53581-1900
Mailing Address - Country:US
Mailing Address - Phone:608-647-6161
Mailing Address - Fax:608-647-3178
Practice Address - Street 1:301 E 2ND ST
Practice Address - Street 2:
Practice Address - City:RICHLAND CENTER
Practice Address - State:WI
Practice Address - Zip Code:53581-1900
Practice Address - Country:US
Practice Address - Phone:608-647-6161
Practice Address - Fax:608-647-3178
Is Sole Proprietor?:No
Enumeration Date:2005-08-04
Last Update Date:2008-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI23207207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI0852480001OtherDMERC
WI30356100Medicaid
WI528514OtherUGS MEDICARE
WI0852480001OtherDMERC