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General NPI Number Information
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NPI Number | 1043328230
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Entity Type | Individual
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Provider Name | WILLIE FORREST RICHARDSON JR. MD
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Gender | Male
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Dates
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Enumeration Date | 08/28/2006
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Last Update Date | 11/03/2011
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Provider Practice Location Address
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Address Line | 1120 BAYVIEW DR
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City | FORT LAUDERDALE
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State | FL
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Zip | 33304-2505
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Country | US
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Telephone | 954-537-4106
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Fax | 954-537-4186
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Provider Business Mailing Address
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Address Line | 1120 BAYVIEW DR
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City | FORT LAUDERDALE
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State | FL
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Zip | 33304-2505
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Country | US
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Telephone | 954-537-4106
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Fax | 954-537-4186
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number | ME94167
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License Number State | FL
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