Healthcare Provider Details

I. General information

NPI: 1922663384
Provider Name (Legal Business Name): VAN-VI LE RICHARDSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2019
Last Update Date: 09/21/2023
Certification Date: 09/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1080 HIGHWAY 35 S
FOREST MS
39074-9423
US

IV. Provider business mailing address

1080 HIGHWAY 35 S
FOREST MS
39074-9423
US

V. Phone/Fax

Practice location:
  • Phone: 601-469-3555
  • Fax: 601-469-3584
Mailing address:
  • Phone: 601-469-3555
  • Fax: 601-469-3584

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number30271
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: