Provider Demographics
NPI:1700828373
Name:THOMAS-RICHARDSON, LAVIDA J (MD)
Entity Type:Individual
Prefix:
First Name:LAVIDA
Middle Name:J
Last Name:THOMAS-RICHARDSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2517 MOMENTUM PL
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60689-0001
Mailing Address - Country:US
Mailing Address - Phone:904-778-9180
Mailing Address - Fax:904-778-9740
Practice Address - Street 1:9580 APPLECROSS RD STE 106
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32222-5843
Practice Address - Country:US
Practice Address - Phone:904-778-9180
Practice Address - Fax:904-778-9740
Is Sole Proprietor?:No
Enumeration Date:2006-06-11
Last Update Date:2009-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME86296207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL276406700Medicaid
FL54249OtherBCBS
GA209336087BMedicaid
GA209336087BMedicaid
FL276406700Medicaid