Provider Demographics
NPI:1760488019
Name:RICHARDS, MARK EDWARD (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:EDWARD
Last Name:RICHARDS
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 1:11300 ROCKVILLE PIKE
Mailing Address - Street 2:STE 912
Mailing Address - City:N BETHESDA
Mailing Address - State:MD
Mailing Address - Zip Code:20852-3034
Mailing Address - Country:US
Mailing Address - Phone:301-468-3458
Mailing Address - Fax:301-468-2076
Practice Address - Street 1:11300 ROCKVILLE PIKE
Practice Address - Street 2:STE 912
Practice Address - City:N BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20852-3034
Practice Address - Country:US
Practice Address - Phone:301-468-3458
Practice Address - Fax:301-468-2076
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-22
Last Update Date:2010-09-09
Deactivation Date:2006-03-15
Deactivation Code:
Reactivation Date:2006-04-05
Provider Licenses
StateLicense IDTaxonomies
MDD0039398208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDE52373Medicare UPIN
MDRI60975Medicare ID - Type Unspecified