Healthcare Provider Details

I. General information

NPI: 1790878932
Provider Name (Legal Business Name): IAN RICHARDSON M.D.,
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 05/01/2026
Certification Date: 05/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

302 S ROUTE 4 STE 207
CHALAN PAGO GU
96910
US

IV. Provider business mailing address

PO BOX 6065
MERIZO GU
96916-0365
US

V. Phone/Fax

Practice location:
  • Phone: 671-477-2873
  • Fax:
Mailing address:
  • Phone: 671-687-9800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberM1238
License Number StateGU

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: