Provider Demographics
NPI:1245644566
Name:RICHMOND, CRAIG (IDC)
Entity type:Individual
Prefix:
First Name:CRAIG
Middle Name:
Last Name:RICHMOND
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9895 ERMA RD
Mailing Address - Street 2:102
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92131-4015
Mailing Address - Country:US
Mailing Address - Phone:845-304-7784
Mailing Address - Fax:
Practice Address - Street 1:9895 ERMA RD
Practice Address - Street 2:102
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92131-4015
Practice Address - Country:US
Practice Address - Phone:845-304-7784
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-14
Last Update Date:2014-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman
Provider Identifiers
StateIdentifier IDID TypeIssuer
202C00000XOtherUS NAVY