Provider Demographics
NPI:1083630123
Name:RICHARDSON, RONALD
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:
Last Name:RICHARDSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:918 W BROADWAY ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:COLLINSVILLE
Mailing Address - State:OK
Mailing Address - Zip Code:74021-2431
Mailing Address - Country:US
Mailing Address - Phone:918-371-6997
Mailing Address - Fax:918-371-6997
Practice Address - Street 1:918 W BROADWAY ST
Practice Address - Street 2:SUITE B
Practice Address - City:COLLINSVILLE
Practice Address - State:OK
Practice Address - Zip Code:74021-2431
Practice Address - Country:US
Practice Address - Phone:918-371-6997
Practice Address - Fax:918-371-6997
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-14
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2-5-1175332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK5703300001Medicare NSC