Provider Demographics
NPI:1457663163
Name:RICHARDSON, JUSTIN NICKLAUS (MD)
Entity type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:NICKLAUS
Last Name:RICHARDSON
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 1:44055 RIVERSIDE PKWY STE 238
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:VA
Mailing Address - Zip Code:20176-5178
Mailing Address - Country:US
Mailing Address - Phone:703-858-8878
Mailing Address - Fax:
Practice Address - Street 1:44055 RIVERSIDE PKWY STE 238
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:VA
Practice Address - Zip Code:20176-5178
Practice Address - Country:US
Practice Address - Phone:703-858-8878
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-10
Last Update Date:2025-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COCDRH.0053765208600000X
CODR.0053765208600000X
VA0101282814208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
COP01401976OtherMEDICARE RAILROAD
CO365056YMMWMedicare PIN