Provider Demographics
NPI:1861537540
Name:RICHARDS, TANIQUE O (MD)
Entity type:Individual
Prefix:
First Name:TANIQUE
Middle Name:O
Last Name:RICHARDS
Suffix:
Gender:F
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:PO BOX 602172
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-2172
Mailing Address - Country:US
Mailing Address - Phone:910-815-5830
Mailing Address - Fax:910-815-5698
Practice Address - Street 1:1625 N GEORGE MASON DR
Practice Address - Street 2:SUITE 425
Practice Address - City:ARLINGTON
Practice Address - State:VA
Practice Address - Zip Code:22205-3683
Practice Address - Country:US
Practice Address - Phone:703-717-4400
Practice Address - Fax:703-717-4401
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2015-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2012-01122207R00000X, 208M00000X
VA0101257194207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5921222Medicaid
SCQ0112PMedicaid
SCQ0112PMedicaid
SCP01109775Medicare PIN