Healthcare Provider Details

I. General information

NPI: 1851338172
Provider Name (Legal Business Name): DANIEL DALE RICHARDSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2006
Last Update Date: 11/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 E 12TH ST
WASHINGTON NC
27889-3408
US

IV. Provider business mailing address

615 E 12TH ST
WASHINGTON NC
27889-3408
US

V. Phone/Fax

Practice location:
  • Phone: 252-946-0181
  • Fax: 252-946-7774
Mailing address:
  • Phone: 252-946-0181
  • Fax: 252-946-7774

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number9600700
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number036263
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: