Provider Demographics
NPI:1205061553
Name:RICHARDSON, DEREK M
Entity type:Individual
Prefix:
First Name:DEREK
Middle Name:M
Last Name:RICHARDSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:DEREK
Other - Middle Name:
Other - Last Name:RICHARDSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:64 BLEECKER ST # 151
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10012-2410
Mailing Address - Country:US
Mailing Address - Phone:302-810-1584
Mailing Address - Fax:
Practice Address - Street 1:315 W 2ND ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-1969
Practice Address - Country:US
Practice Address - Phone:252-507-0588
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-15
Last Update Date:2021-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0053968207Q00000X, 208M00000X
VA0101248338207Q00000X
NC2015-02469208M00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO90007743Medicaid
CO359238YL2GMedicare PIN