Basic Information
| Provider Information | |||||||||
| NPI: | 1457663163 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RICHARDSON | ||||||||
| FirstName: | JUSTIN | ||||||||
| MiddleName: | NICKLAUS | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4743 ARAPAHOE AVE STE 100 | ||||||||
| Address2: | |||||||||
| City: | BOULDER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 803031123 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3034432123 | ||||||||
| FaxNumber: | 3034439497 | ||||||||
| Practice Location | |||||||||
| Address1: | 4743 ARAPAHOE AVE STE 100 | ||||||||
| Address2: | |||||||||
| City: | BOULDER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 803031123 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3034432123 | ||||||||
| FaxNumber: | 3034439497 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2010 | ||||||||
| LastUpdateDate: | 07/07/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/07/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | DR.0053765 | CO | N | Allopathic & Osteopathic Physicians | Surgery | 208600000X | CDRH.0053765 | CO | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | P01401976 | 01 | CO | MEDICARE RAILROAD | OTHER |