Provider Demographics
NPI:1346251063
Name:RICHARDSON, NORMAN GREGORY (OD)
Entity Type:Individual
Prefix:
First Name:NORMAN
Middle Name:GREGORY
Last Name:RICHARDSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:N
Other - Middle Name:GREGORY
Other - Last Name:RICHARDSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:475 YELLOWSTONE AVE
Mailing Address - Street 2:SUITE G
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-4528
Mailing Address - Country:US
Mailing Address - Phone:208-233-1551
Mailing Address - Fax:208-232-7896
Practice Address - Street 1:475 YELLOWSTONE AVE
Practice Address - Street 2:SUITE G
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-4528
Practice Address - Country:US
Practice Address - Phone:208-233-1551
Practice Address - Fax:208-232-7896
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-10
Last Update Date:2017-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP680152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002555400Medicaid
ID0581090001Medicare NSC
ID1591361Medicare PIN