Provider Demographics
NPI:1992727150
Name:RICHARDSON, DERRICK L (MD)
Entity type:Individual
Prefix:DR
First Name:DERRICK
Middle Name:L
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:PO BOX 3528
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72913-3528
Mailing Address - Country:US
Mailing Address - Phone:479-274-2000
Mailing Address - Fax:479-274-2194
Practice Address - Street 1:6801 ROGERS AVE
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-4067
Practice Address - Country:US
Practice Address - Phone:479-274-3200
Practice Address - Fax:479-274-3289
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2015-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC-8460207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR129829001Medicaid
010063815OtherRR MEDICARE
AR129829001Medicaid
010063815OtherRR MEDICARE