Provider Demographics
NPI:1689848103
Name:RICHARDSON, MARA C
Entity Type:Individual
Prefix:
First Name:MARA
Middle Name:C
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:810 CLAIRTON BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15236-4519
Mailing Address - Country:US
Mailing Address - Phone:412-466-5004
Mailing Address - Fax:412-466-7137
Practice Address - Street 1:4070 BEECHWOOD BLVD
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15217-2679
Practice Address - Country:US
Practice Address - Phone:412-521-6511
Practice Address - Fax:412-521-6512
Is Sole Proprietor?:No
Enumeration Date:2008-04-15
Last Update Date:2017-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD442871208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics