Provider Demographics
NPI:1700867215
Name:RICHARDSON, DONALD (MD)
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:
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:PO BOX 23340
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63156-3340
Mailing Address - Country:US
Mailing Address - Phone:314-849-6000
Mailing Address - Fax:314-849-1417
Practice Address - Street 1:12345 W BEND DR
Practice Address - Street 2:SUITE 300
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63128-2182
Practice Address - Country:US
Practice Address - Phone:314-849-6000
Practice Address - Fax:314-849-1417
Is Sole Proprietor?:No
Enumeration Date:2005-11-10
Last Update Date:2012-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR6979207QG0300X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO4214916OtherAETNA
MO000000010031OtherESSENCE
MO9184OtherBCBS
MO201659414Medicaid
MOA10039OtherMERCY
MO127486OtherGHP
MO0400272OtherUHC
MO114793OtherHEALTHLINK
MOA10039Medicare UPIN
MO0400272OtherUHC
MO201659414Medicaid