Provider Demographics
NPI:1104083427
Name:RICHARDSON, REGINALD BARNETTE JR (DPM)
Entity type:Individual
Prefix:DR
First Name:REGINALD
Middle Name:BARNETTE
Last Name:RICHARDSON
Suffix:JR
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 668093
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28266-8093
Mailing Address - Country:US
Mailing Address - Phone:704-737-6126
Mailing Address - Fax:
Practice Address - Street 1:3333 WILKINSON BLVD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28208-5631
Practice Address - Country:US
Practice Address - Phone:704-737-6126
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-22
Last Update Date:2008-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC310213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2432063Medicare PIN
NC1189370001Medicare NSC
NCU20739Medicare UPIN