Healthcare Provider Details

I. General information

NPI: 1467711754
Provider Name (Legal Business Name): JACK RICHMAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/08/2012
Last Update Date: 10/14/2020
Certification Date: 10/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

264 ELTON PARK ROAD
OAKVILLE ONTARIO
L6J 4C1
CA

IV. Provider business mailing address

264 ELTON PARK ROAD
OAKVILLE ONTARIO
L6J 4C1
CA

V. Phone/Fax

Practice location:
  • Phone: 905-849-1133
  • Fax: 905-845-0247
Mailing address:
  • Phone: 905-849-1133
  • Fax: 905-845-0247

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number042-0007249
License Number StateVT
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number21406
License Number StateZZ
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number042.0007249
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: