Basic Information
| Provider Information | |||||||||
| NPI: | 1407052459 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RICHARDSON | ||||||||
| FirstName: | HENRY | ||||||||
| MiddleName: | ABLE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 224 N FAIR OAKS AVE STE 300 | ||||||||
| Address2: | |||||||||
| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911033618 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6266961400 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 7525 METROPOLITAN DR STE 302 | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921084404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6193251161 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2007 | ||||||||
| LastUpdateDate: | 04/11/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2081P2900X | A105294 | CA | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 102960467 | 05 | PA | MEDICAID |