Provider Demographics
NPI:1285895938
Name:RICHARDS, MARK ALLEN (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:ALLEN
Last Name:RICHARDS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:4605 MACCORKLE AVE SW
Mailing Address - Street 2:
Mailing Address - City:SOUTH CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25309-1311
Mailing Address - Country:US
Mailing Address - Phone:304-414-4800
Mailing Address - Fax:
Practice Address - Street 1:500 DONNALLY ST
Practice Address - Street 2:SUITE 203
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25301-1648
Practice Address - Country:US
Practice Address - Phone:304-347-6700
Practice Address - Fax:304-347-6841
Is Sole Proprietor?:No
Enumeration Date:2008-06-24
Last Update Date:2021-12-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WV24449207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVB441OtherGROUP MEDICARE
WV3810024049OtherGROUP MEDICAID
WV3810021130Medicaid
WVB441OtherGROUP MEDICARE