Healthcare Provider Details

I. General information

NPI: 1770872186
Provider Name (Legal Business Name): THEOBALD STANLEY RICHARDS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/06/2011
Last Update Date: 04/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1452 PRESIDENT ST
BROOKLYN NY
11213-4435
US

IV. Provider business mailing address

1452 PRESIDENT ST
BROOKLYN NY
11213-4435
US

V. Phone/Fax

Practice location:
  • Phone: 718-493-7397
  • Fax:
Mailing address:
  • Phone: 718-493-7397
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number100043
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: