Provider Demographics
NPI:1063619765
Name:RICHMOND, DAVID S (MD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:S
Last Name:RICHMOND
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:HC 67 BOX 680
Mailing Address - Street 2:
Mailing Address - City:CLAYTON
Mailing Address - State:ID
Mailing Address - Zip Code:83227-9702
Mailing Address - Country:US
Mailing Address - Phone:208-838-2431
Mailing Address - Fax:
Practice Address - Street 1:HC 67 BOX 680
Practice Address - Street 2:
Practice Address - City:CLAYTON
Practice Address - State:ID
Practice Address - Zip Code:83227-9702
Practice Address - Country:US
Practice Address - Phone:208-838-2431
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM6268174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID41877Medicare UPIN
ID1129574Medicare ID - Type Unspecified