Healthcare Provider Details

I. General information

NPI: 1760892095
Provider Name (Legal Business Name): THEODORE DAVID RICHARDS JR. D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2014
Last Update Date: 08/15/2022
Certification Date: 08/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

611 ALCORN DR
CORINTH MS
38834-9321
US

IV. Provider business mailing address

611 ALCORN DR
CORINTH MS
38834-9321
US

V. Phone/Fax

Practice location:
  • Phone: 166-229-3768
  • Fax:
Mailing address:
  • Phone: 166-229-3768
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number24089
License Number StateMS
# 3
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number05828
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: