Healthcare Provider Details

I. General information

NPI: 1639439086
Provider Name (Legal Business Name): JUSTIN DAN RICHEY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2012
Last Update Date: 09/09/2025
Certification Date: 09/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4351 TAMIAMI TRL N
NAPLES FL
34103-3106
US

IV. Provider business mailing address

4351 TAMIAMI TRL N
NAPLES FL
34103-3106
US

V. Phone/Fax

Practice location:
  • Phone: 816-241-3338
  • Fax: 239-263-6983
Mailing address:
  • Phone: 239-263-1777
  • Fax: 239-263-6983

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number2017005705
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number01076195A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License NumberC3839
License Number StateKY
# 4
Primary TaxonomyY
Taxonomy Code207ZD0900X
TaxonomyDermatopathology (Pathology) Physician
License Number04-39695
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: