Healthcare Provider Details

I. General information

NPI: 1063401925
Provider Name (Legal Business Name): CHARLIE E RICHARDSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/13/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

309 NE MARION ST
MADISON FL
32340-2511
US

IV. Provider business mailing address

2740 HICKORY RIDGE RD
TALLAHASSEE FL
32308-4010
US

V. Phone/Fax

Practice location:
  • Phone: 850-973-3456
  • Fax: 850-973-9399
Mailing address:
  • Phone: 850-552-0922
  • Fax: 850-553-6192

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberME30397
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: