Provider Demographics
NPI:1336183755
Name:RICHMOND, JUDITH A (MD)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:A
Last Name:RICHMOND
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 1:4805 NE GLISAN ST STE 4J14
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97213-2933
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4805 NE GLISAN ST STE 4J14
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-2933
Practice Address - Country:US
Practice Address - Phone:503-215-5545
Practice Address - Fax:503-215-6012
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-15
Last Update Date:2021-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD25244208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR022775Medicaid
OR022775Medicaid
ORR161173Medicare PIN