Provider Demographics
NPI:1700953940
Name:RICHARDSON, WENDELL L (MD)
Entity Type:Individual
Prefix:
First Name:WENDELL
Middle Name:L
Last Name:RICHARDSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1212 S WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:FAIRMONT
Mailing Address - State:NC
Mailing Address - Zip Code:28340-1848
Mailing Address - Country:US
Mailing Address - Phone:910-628-6711
Mailing Address - Fax:910-628-5735
Practice Address - Street 1:1212 S WALNUT ST
Practice Address - Street 2:
Practice Address - City:FAIRMONT
Practice Address - State:NC
Practice Address - Zip Code:28340-1848
Practice Address - Country:US
Practice Address - Phone:910-628-6711
Practice Address - Fax:910-628-5735
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2006-01430207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC144CAOtherBCBS OF NC
NC5905736Medicaid
NC5905736Medicaid
NC2062051CMedicare ID - Type UnspecifiedS ROBESON MEDICAL CENTER
NC2062051Medicare ID - Type UnspecifiedLUMBERTON HEALTH CENTER
NC2062051AMedicare ID - Type UnspecifiedJULIAN T PIERCE HLTH CTR
NC2062051BMedicare ID - Type UnspecifiedMAXTON MEDICAL CENTER