Provider Demographics
NPI:1922157106
Name:RICHARDSON, DANTE (MD)
Entity Type:Individual
Prefix:DR
First Name:DANTE
Middle Name:
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 1:2425 N SALISBURY BLVD
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:MD
Mailing Address - Zip Code:21801-2138
Mailing Address - Country:US
Mailing Address - Phone:443-944-0196
Mailing Address - Fax:410-944-0192
Practice Address - Street 1:2425 N SALISBURY BLVD
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:MD
Practice Address - Zip Code:21801-2138
Practice Address - Country:US
Practice Address - Phone:443-944-0196
Practice Address - Fax:410-944-0192
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2018-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD77762207Q00000X
VA0101246050207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1922157106Medicaid
VAP00931166Medicare PIN
VAVV0904AMedicare PIN