Healthcare Provider Details

I. General information

NPI: 1295050342
Provider Name (Legal Business Name): CORY GLEN RICHARDSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/01/2010
Last Update Date: 10/07/2025
Certification Date: 10/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3318 N GRANDMILL LN
COEUR D ALENE ID
83814-5689
US

IV. Provider business mailing address

3318 N GRANDMILL LN
COEUR D ALENE ID
83814-5689
US

V. Phone/Fax

Practice location:
  • Phone: 208-292-0445
  • Fax: 208-772-6514
Mailing address:
  • Phone: 208-292-0445
  • Fax: 208-772-6514

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberM-13357
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code207RB0002X
TaxonomyObesity Medicine (Internal Medicine) Physician
License NumberM-13357
License Number StateID
# 3
Primary TaxonomyN
Taxonomy Code2086S0127X
TaxonomyTrauma Surgery Physician
License NumberM-13357
License Number StateID
# 4
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberM-13357
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: