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General NPI Number Information
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NPI Number | 1174605067
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Entity Type | Individual
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Provider Name | KENNETH EDWIN RICHTER JR. D.O.
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Gender | Male
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Dates
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Enumeration Date | 10/19/2006
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Last Update Date | 07/29/2021
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Provider Practice Location Address
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Address Line | 1904 RICHLAND AVE
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City | CERES
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State | CA
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Zip | 95307-4562
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Country | US
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Telephone | 209-300-8800
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Fax |
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Provider Business Mailing Address
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Address Line | 3601 PICKETT RD UNIT 2489
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City | FAIRFAX
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State | VA
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Zip | 22031-8123
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Country | US
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Telephone | 619-203-2426
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Fax |
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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 | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 20A10813
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number | 4168
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License Number State | AZ
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Taxonomy #3
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | 20A10813
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License Number State | CA
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