Provider Demographics
NPI:1881673259
Name:RICHARDSON, JARED LEE (MD)
Entity Type:Individual
Prefix:DR
First Name:JARED
Middle Name:LEE
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:PO BOX 201606
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75320-1606
Mailing Address - Country:US
Mailing Address - Phone:972-519-1940
Mailing Address - Fax:
Practice Address - Street 1:4401 BOOTH CALLOWAY RD
Practice Address - Street 2:
Practice Address - City:NORTH RICHLAND HILLS
Practice Address - State:TX
Practice Address - Zip Code:76180-7371
Practice Address - Country:US
Practice Address - Phone:972-540-4919
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-12
Last Update Date:2007-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL7139207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP00054126OtherMEDICARE RAILROAD
TX8F6637OtherBCBS
TX8F6637OtherBCBS