# TIMOTHY F. RICHARDSON, M.D., A MEDICAL CORPORATION

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- **Entity:** Organization
- **Status:** Active
- **Other names:** Mirage Dermatology Medical Associates, Inc.
- **Organization subpart:** No

## Provider details

- **NPI number:** 1346262375
- **Authorized official:** DR. TIMOTHY RICHARDSON M.D. (PRESIDENT)
- **Authorized official phone:** (760) 341-1999

## Contact information

- **Practice address:** 36867 COOK ST, SUITE 101, PALM DESERT, CA 92211-6064
- **Practice address phone:** (760) 341-1999
- **Practice address fax:** (760) 341-1997
- **Mailing address:** PO BOX 1486, RANCHO MIRAGE, CA 92270-1049
- **Mailing address phone:** (760) 341-1999
- **Mailing address fax:** (760) 341-1997

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 261QM2500X | Medical Specialty Clinic/Center | G53073 | CA | Yes |

## Other

- **Enumeration date:** 07/25/2006
- **Last updated:** 06/28/2021

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | ZZZ23174Z | MEDICARE PTAN | CA |