Provider Demographics
NPI:1114474723
Name:RICHARDSON, MICHAEL BLAKE (MD, DPT)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:BLAKE
Last Name:RICHARDSON
Suffix:
Gender:M
Credentials:MD, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2185 SUGAR CREEK DR
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72034-9603
Mailing Address - Country:US
Mailing Address - Phone:870-250-0183
Mailing Address - Fax:
Practice Address - Street 1:3201 SPRINGHILL DR STE 300
Practice Address - Street 2:
Practice Address - City:NORTH LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72117-2909
Practice Address - Country:US
Practice Address - Phone:501-753-4132
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-01
Last Update Date:2021-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPT4227225100000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist