Provider Demographics
NPI:1205606951
Name:RICHARDSON, MARK WAYNE (ACUPUNCTURIST)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:WAYNE
Last Name:RICHARDSON
Suffix:
Gender:M
Credentials:ACUPUNCTURIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1518 WALNUT ST STE 1306
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19102-3401
Mailing Address - Country:US
Mailing Address - Phone:215-817-1298
Mailing Address - Fax:215-735-0079
Practice Address - Street 1:7750 MONTPELIER RD
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20723-6010
Practice Address - Country:US
Practice Address - Phone:215-817-1298
Practice Address - Fax:215-735-0079
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-04
Last Update Date:2024-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDU02991171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist