Healthcare Provider Details

I. General information

NPI: 1265848576
Provider Name (Legal Business Name): JOHN M RICHARDSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2014
Last Update Date: 04/11/2024
Certification Date: 04/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18TH MEDICAL GROUP UNIT 5142
APO AP
96368-5142
US

IV. Provider business mailing address

UNIT 5142 BOX 18TH
APO AP
96368-5142
US

V. Phone/Fax

Practice location:
  • Phone: 315-634-9344
  • Fax:
Mailing address:
  • Phone: 315-634-9344
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number0101260556
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0116027332
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: