Provider Demographics
NPI:1154717742
Name:HEATHER RICHARDSON, MD
Entity type:Organization
Organization Name:HEATHER RICHARDSON, MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE OWNER AND PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:
Authorized Official - Last Name:RICHARDSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:404-358-5553
Mailing Address - Street 1:436 N BEDFORD DR
Mailing Address - Street 2:SUITE 105
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90210-4310
Mailing Address - Country:US
Mailing Address - Phone:310-278-8590
Mailing Address - Fax:310-278-8230
Practice Address - Street 1:436 N BEDFORD DR
Practice Address - Street 2:SUITE 105
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90210-4310
Practice Address - Country:US
Practice Address - Phone:310-278-8590
Practice Address - Fax:310-278-8230
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-09
Last Update Date:2015-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA132043208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
I08403Medicare UPIN