Provider Demographics
NPI:1750591004
Name:RICHARDSON, HEATHER (DO)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 N 16TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW CASTLE
Mailing Address - State:IN
Mailing Address - Zip Code:47362-4319
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3817 MAIN ST
Practice Address - Street 2:
Practice Address - City:LORIS
Practice Address - State:SC
Practice Address - Zip Code:29569-3017
Practice Address - Country:US
Practice Address - Phone:843-663-8013
Practice Address - Fax:843-663-8166
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC83408208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP01456956OtherRAIL ROAD PTAN
IN000000639725OtherANTHERM
IN200953400Medicaid
IN719300GGMedicare PIN
IN266180465Medicare PIN