Provider Demographics
NPI:1811994221
Name:RICHARDSON, GREGORY B (MD, FACS)
Entity type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:B
Last Name:RICHARDSON
Suffix:
Gender:M
Credentials:MD, FACS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 10TH ST
Mailing Address - Street 2:
Mailing Address - City:ALAMOGORDO
Mailing Address - State:NM
Mailing Address - Zip Code:88310-6414
Mailing Address - Country:US
Mailing Address - Phone:575-437-2244
Mailing Address - Fax:575-437-8000
Practice Address - Street 1:1100 10TH ST
Practice Address - Street 2:
Practice Address - City:ALAMOGORDO
Practice Address - State:NM
Practice Address - Zip Code:88310-6414
Practice Address - Country:US
Practice Address - Phone:505-437-2244
Practice Address - Fax:505-437-8000
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-30
Last Update Date:2017-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM76251174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM00017137Medicaid
NM00017137Medicaid
NM2131984Medicare ID - Type UnspecifiedMEDICARE ID