Provider Demographics
NPI:1689755084
Name:RICHMOND, DPM, TANISHA RENEE (DPM)
Entity Type:Individual
Prefix:DR
First Name:TANISHA
Middle Name:RENEE
Last Name:RICHMOND, DPM
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1323 W 3RD ST
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45402-6714
Mailing Address - Country:US
Mailing Address - Phone:937-228-3668
Mailing Address - Fax:937-228-3660
Practice Address - Street 1:1323 W 3RD ST
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45402-6714
Practice Address - Country:US
Practice Address - Phone:937-228-3668
Practice Address - Fax:937-228-3660
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-18
Last Update Date:2011-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36-003457213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000558908OtherANTHEM
OH2796292Medicaid
OH$$$$$$$$$00OtherBWC
OH000000558908OtherANTHEM
4227681Medicare PIN
OH6152890001Medicare NSC