Provider Demographics
NPI:1447297023
Name:RICHARDSON, GARY DALE (DO)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:DALE
Last Name:RICHARDSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7021 MILITIA HILL ST NW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44718
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:400 AUSTIN AVE NW
Practice Address - Street 2:
Practice Address - City:MASSILLON
Practice Address - State:OH
Practice Address - Zip Code:44646-3598
Practice Address - Country:US
Practice Address - Phone:216-837-7200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-01
Last Update Date:2020-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34003395207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0498135Medicaid
OHP00332912OtherMEDICARE TRAVELERS RR-GA
OH942460636442OtherCARESOURCE
OHRI0517775Medicare PIN
OHE00679Medicare UPIN
OHP00332912OtherMEDICARE TRAVELERS RR-GA