Provider Demographics
NPI:1972827582
Name:RICHARDSON, CARISSA M (MD)
Entity Type:Individual
Prefix:DR
First Name:CARISSA
Middle Name:M
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:980 W IRONWOOD DR #101
Mailing Address - Street 2:
Mailing Address - City:COEUR D'ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814
Mailing Address - Country:US
Mailing Address - Phone:208-765-1455
Mailing Address - Fax:208-667-2556
Practice Address - Street 1:980 W IRONWOOD DR #101
Practice Address - Street 2:
Practice Address - City:COEUR D'ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814
Practice Address - Country:US
Practice Address - Phone:208-765-1455
Practice Address - Fax:208-667-2556
Is Sole Proprietor?:No
Enumeration Date:2010-03-25
Last Update Date:2016-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-13322207V00000X
NV15289207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology