Healthcare Provider Details

I. General information

NPI: 1629643515
Provider Name (Legal Business Name): GRANT RICHARDSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2021
Last Update Date: 09/11/2024
Certification Date: 09/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 PINOLE VALLEY RD
PINOLE CA
94564-1384
US

IV. Provider business mailing address

1699 MARKET ST APT 12
SAN FRANCISCO CA
94103-1244
US

V. Phone/Fax

Practice location:
  • Phone: 510-243-4000
  • Fax:
Mailing address:
  • Phone: 724-413-5805
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number20A22558
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: