Healthcare Provider Details

I. General information

NPI: 1902081813
Provider Name (Legal Business Name): JASON P RICHARDS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/09/2008
Last Update Date: 12/06/2021
Certification Date: 12/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2240 E CENTER ST
POCATELLO ID
83201
US

IV. Provider business mailing address

393 E WALNUT ST PHR GROUP PROVIDER ENROLLMENT UNIT, 3RD FL
PASADENA CA
91188-0001
US

V. Phone/Fax

Practice location:
  • Phone: 208-233-8344
  • Fax: 208-233-6983
Mailing address:
  • Phone: 626-405-7914
  • Fax: 626-405-4600

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License NumberA120201
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: