Provider Demographics
NPI:1205355468
Name:RICHARDSON READUS, KORTNEY JAMAL
Entity type:Individual
Prefix:
First Name:KORTNEY
Middle Name:JAMAL
Last Name:RICHARDSON READUS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10332 MAIN ST # 344
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-2410
Mailing Address - Country:US
Mailing Address - Phone:815-272-6652
Mailing Address - Fax:
Practice Address - Street 1:10332 MAIN ST # 344
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-2410
Practice Address - Country:US
Practice Address - Phone:815-272-6652
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-19
Last Update Date:2017-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant