Healthcare Provider Details

I. General information

NPI: 1407876352
Provider Name (Legal Business Name): MARK RICHEY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2006
Last Update Date: 01/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

155 GLASSON WAY
GRASS VALLEY CA
95945-5723
US

IV. Provider business mailing address

P.O.1766
INDIANAPOLIS IN
46206-1766
US

V. Phone/Fax

Practice location:
  • Phone: 530-274-6107
  • Fax: 530-274-6059
Mailing address:
  • Phone: 530-241-0473
  • Fax: 530-241-5377

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberG54942
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: