Provider Demographics
NPI:1295050342
Name:RICHARDSON, CORY GLEN (MD)
Entity type:Individual
Prefix:DR
First Name:CORY
Middle Name:GLEN
Last Name:RICHARDSON
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:1593 E POLSTON AVE
Mailing Address - Street 2:
Mailing Address - City:POST FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83854-5326
Mailing Address - Country:US
Mailing Address - Phone:208-262-2300
Mailing Address - Fax:208-262-2390
Practice Address - Street 1:750 N SYRINGA ST STE 205
Practice Address - Street 2:
Practice Address - City:POST FALLS
Practice Address - State:ID
Practice Address - Zip Code:83854-5275
Practice Address - Country:US
Practice Address - Phone:208-262-0945
Practice Address - Fax:208-425-0150
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-01
Last Update Date:2025-04-14
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IDM-13357208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1295050342Medicaid
ID1295050342Medicaid