Provider Demographics
NPI:1679536981
Name:RICHARDSON, MICHELLE L (MD)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:L
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 TOTMAN STREET STE 2
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:MA
Mailing Address - Zip Code:02169
Mailing Address - Country:US
Mailing Address - Phone:617-745-0050
Mailing Address - Fax:617-745-0052
Practice Address - Street 1:21 TOTMAN STREET STE 2
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:MA
Practice Address - Zip Code:02169
Practice Address - Country:US
Practice Address - Phone:617-745-0050
Practice Address - Fax:617-745-0052
Is Sole Proprietor?:No
Enumeration Date:2006-04-08
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA215884208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAJ26819OtherBCBS
MA2061040Medicaid
MAAA13696OtherHPHC
MAJ26819OtherBCBS
A36749Medicare ID - Type Unspecified