Healthcare Provider Details

I. General information

NPI: 1629363072
Provider Name (Legal Business Name): PHILLIP E RICHARDSON D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2011
Last Update Date: 04/29/2024
Certification Date: 04/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7701 W ASPERA BLVD
GLENDALE AZ
85308-7947
US

IV. Provider business mailing address

7701 W ASPERA BLVD
GLENDALE AZ
85308-7947
US

V. Phone/Fax

Practice location:
  • Phone: 623-248-2100
  • Fax:
Mailing address:
  • Phone: 623-248-2100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number041394
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number07001258A
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number041394
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: