Healthcare Provider Details

I. General information

NPI: 1174605067
Provider Name (Legal Business Name): KENNETH EDWIN RICHTER JR. D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/19/2006
Last Update Date: 07/29/2021
Certification Date: 07/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1904 RICHLAND AVE
CERES CA
95307-4562
US

IV. Provider business mailing address

3601 PICKETT RD UNIT 2489
FAIRFAX VA
22031-8123
US

V. Phone/Fax

Practice location:
  • Phone: 209-300-8800
  • Fax:
Mailing address:
  • Phone: 619-203-2426
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number20A10813
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number4168
License Number StateAZ
# 3
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number20A10813
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: