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General NPI Number Information
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NPI Number | 1295050342
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Entity Type | Individual
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Provider Name | CORY GLEN RICHARDSON MD
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Gender | Male
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Dates
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Enumeration Date | 04/01/2010
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Last Update Date | 10/07/2025
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Provider Practice Location Address
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Address Line | 3318 N GRANDMILL LN
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City | COEUR D ALENE
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State | ID
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Zip | 83814-5689
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Country | US
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Telephone | 208-292-0445
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Fax | 208-772-6514
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Provider Business Mailing Address
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Address Line | 3318 N GRANDMILL LN
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City | COEUR D ALENE
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State | ID
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Zip | 83814-5689
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Country | US
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Telephone | 208-292-0445
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Fax | 208-772-6514
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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 | 208600000X
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Taxonomy Name | Surgery Physician
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License Number | M-13357
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License Number State | ID
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Taxonomy #2
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Taxonomy Code | 207RB0002X
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Taxonomy Name | Obesity Medicine (Internal Medicine) Physician
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License Number | M-13357
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License Number State | ID
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Taxonomy #3
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Taxonomy Code | 2086S0127X
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Taxonomy Name | Trauma Surgery Physician
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License Number | M-13357
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License Number State | ID
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Taxonomy #4
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Taxonomy Code | 207RG0100X
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Taxonomy Name | Gastroenterology Physician
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License Number | M-13357
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License Number State | ID
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