Basic Information
| Provider Information | |||||||||
| NPI: | 1447241112 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RICHARDSON | ||||||||
| FirstName: | CLIF | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | DPM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8160 YMCA PLAZA DR | ||||||||
| Address2: | SUITE C | ||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708100916 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2257637770 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 8160 YMCA PLAZA DR | ||||||||
| Address2: | SUITE C | ||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708100916 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2257637770 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2005 | ||||||||
| LastUpdateDate: | 10/03/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0131X | PD317R | LA | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1369691 | 05 | LA | MEDICAID |