Healthcare Provider Details

I. General information

NPI: 1811492416
Provider Name (Legal Business Name): KYLE RICHARDSON DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/26/2018
Last Update Date: 09/21/2026
Certification Date: 09/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BLDG AS4021 CANAL ST
JACKSONVILLE NC
28540
US

IV. Provider business mailing address

U.S. MARINE CORPS FORCES COMMAND ATTN: CREDENTIALS NH41 1775 FORRESTAL DRIVE
NORFOLK VA
23551-2400
US

V. Phone/Fax

Practice location:
  • Phone: 910-449-7700
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083A0100X
TaxonomyAerospace Medicine Physician
License Number02005764A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: