Provider Demographics
NPI:1700835204
Name:RICHESON, COBY T (MD)
Entity Type:Individual
Prefix:
First Name:COBY
Middle Name:T
Last Name:RICHESON
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 1:10421 E COUNTY ROAD 100 N
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46234-1243
Mailing Address - Country:US
Mailing Address - Phone:317-272-7013
Mailing Address - Fax:317-272-7007
Practice Address - Street 1:10421 E COUNTY ROAD 100 N
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46234-1243
Practice Address - Country:US
Practice Address - Phone:317-272-7013
Practice Address - Fax:317-272-7007
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01053052A207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000244563OtherANTHEM
IN200387460Medicaid
IN200387460Medicaid
INH76114Medicare UPIN
INP01047665Medicare PIN
IN715530Q9Medicare PIN