Provider Demographics
NPI:1740230721
Name:RICHARDSON, HOMER ALLEN (MD)
Entity Type:Individual
Prefix:
First Name:HOMER
Middle Name:ALLEN
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 1:2100 POWELL STREET
Mailing Address - Street 2:
Mailing Address - City:EMERYVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:94608-1803
Mailing Address - Country:US
Mailing Address - Phone:510-350-2777
Mailing Address - Fax:
Practice Address - Street 1:2701 NORTH DECATUR ROAD
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033
Practice Address - Country:US
Practice Address - Phone:404-501-1849
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2013-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA49993207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100224220Medicaid
000000799022OtherBCBS-BAPTIST
KYP01209417OtherMEDICARE RAILROAD
GAH27849Medicare UPIN
KY7100224220Medicaid