MEDICARE: WILLIE FORREST RICHARDSON JR. MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207N00000X	Dermatology Physician	ME94167	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1043328230
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WILLIE FORREST RICHARDSON JR. MD

Provider Business Mailing Address
First Line	:	1120 BAYVIEW DR
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33304-2505
Country	:	US
Telephone Number	:	954-537-4106
Fax Number	:	954-537-4186

Provider Business Practice Location Address
First Line	:	1120 BAYVIEW DR
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33304-2505
Country	:	US
Telephone Number	:	954-537-4106
Fax Number	:	954-537-4186

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/28/2006
Last Update Date	:	11/03/2011

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