Provider Demographics
NPI:1194720102
Name:RICHARDSON, PETER BRUCE (MD)
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:BRUCE
Last Name:RICHARDSON
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 1:17 N MEDICAL PARK DR
Mailing Address - Street 2:
Mailing Address - City:FISHERSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22939-2344
Mailing Address - Country:US
Mailing Address - Phone:540-213-7725
Mailing Address - Fax:540-213-7481
Practice Address - Street 1:1500 COMMERCE RD
Practice Address - Street 2:
Practice Address - City:STAUNTON
Practice Address - State:VA
Practice Address - Zip Code:24401
Practice Address - Country:US
Practice Address - Phone:540-213-0060
Practice Address - Fax:540-213-9441
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2010-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101032138174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
180020459OtherRAILROAD MEDICARE
VA059755OtherBLUE CROSS BLUE SHIELD
VA006301754Medicaid
180020459OtherRAILROAD MEDICARE
VA059755OtherBLUE CROSS BLUE SHIELD