Provider Demographics
NPI:1215095773
Name:RICHARDSON, GREGORY V (MD)
Entity type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:V
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 1:505 N. WABASH AVE
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IN
Mailing Address - Zip Code:46952
Mailing Address - Country:US
Mailing Address - Phone:765-662-3971
Mailing Address - Fax:765-668-6718
Practice Address - Street 1:505 N. WABASH AVE
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IN
Practice Address - Zip Code:46952
Practice Address - Country:US
Practice Address - Phone:765-662-3971
Practice Address - Fax:765-668-6718
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2010-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN010322822084P0800X
IN01032282A2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100323530Medicaid
IN100323530Medicaid
IN957350EMedicare ID - Type Unspecified