Provider Demographics
NPI:1851338172
Name:RICHARDSON, DANIEL DALE (MD)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:DALE
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 1:615 E 12TH ST
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27889-3408
Mailing Address - Country:US
Mailing Address - Phone:252-946-0181
Mailing Address - Fax:252-946-7774
Practice Address - Street 1:615 E 12TH ST
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:NC
Practice Address - Zip Code:27889-3408
Practice Address - Country:US
Practice Address - Phone:252-946-0181
Practice Address - Fax:252-946-7774
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2012-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9600700208600000X
GA036263208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCP00322237OtherRAILROAD MEDICARE
NC2223843BOtherAETNA
NC7908120OtherAETNA
NCG27631Medicare UPIN
NCP00322237OtherRAILROAD MEDICARE