Provider Demographics
NPI:1760453948
Name:RICHARDSON, MARC A (MD)
Entity Type:Individual
Prefix:DR
First Name:MARC
Middle Name:A
Last Name:RICHARDSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5502 DIXIE HWY
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45014-4297
Mailing Address - Country:US
Mailing Address - Phone:513-874-9460
Mailing Address - Fax:513-874-5731
Practice Address - Street 1:5502 DIXIE HWY
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:OH
Practice Address - Zip Code:45014-4297
Practice Address - Country:US
Practice Address - Phone:513-874-9460
Practice Address - Fax:513-874-5731
Is Sole Proprietor?:No
Enumeration Date:2006-01-27
Last Update Date:2016-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35071381208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2093569Medicaid
OHG76224Medicare UPIN