Provider Demographics
NPI:1801814975
Name:RICHARDSON, ROBERT LEN (PHD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:LEN
Last Name:RICHARDSON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1575 N VAN NESS AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93728-1940
Mailing Address - Country:US
Mailing Address - Phone:559-266-2694
Mailing Address - Fax:559-266-0811
Practice Address - Street 1:1575 N VAN NESS AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93728-1940
Practice Address - Country:US
Practice Address - Phone:559-266-2694
Practice Address - Fax:559-266-0811
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY7287174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPTX072870Medicaid
CA00PL72871Medicare UPIN