Provider Demographics
NPI:1679689368
Name:LONDON, RICHARD L (MD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:L
Last Name:LONDON
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 1:9721 N LAKE DR
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53217-6103
Mailing Address - Country:US
Mailing Address - Phone:414-375-9040
Mailing Address - Fax:877-991-8133
Practice Address - Street 1:9721 N LAKE DR
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53217-6103
Practice Address - Country:US
Practice Address - Phone:414-375-9040
Practice Address - Fax:877-991-8133
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-22
Last Update Date:2022-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI26420207Q00000X, 207QG0300X, 207QH0002X, 207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
No207QH0002XAllopathic & Osteopathic PhysiciansFamily MedicineHospice and Palliative Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIB54657Medicare UPIN