Provider Demographics
NPI:1033211230
Name:RICHARDSON, MATTHEW SCOT (OD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:SCOT
Last Name:RICHARDSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:853 NE A ST
Mailing Address - Street 2:
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97526-2211
Mailing Address - Country:US
Mailing Address - Phone:541-474-2788
Mailing Address - Fax:541-474-0516
Practice Address - Street 1:853 NE A ST
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97526-2211
Practice Address - Country:US
Practice Address - Phone:541-474-2788
Practice Address - Fax:541-474-0516
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2980ATI152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR276057Medicaid
OR2980ATIOtherSTATE LICENSE
OR2980ATIOtherSTATE LICENSE
OR2980ATIOtherSTATE LICENSE