Provider Demographics
NPI:1346924347
Name:RICHARDSON, MATTHEW CRAWFORD
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:CRAWFORD
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 1:11510 SE SUNNYSIDE RD APT 16
Mailing Address - Street 2:
Mailing Address - City:CLACKAMAS
Mailing Address - State:OR
Mailing Address - Zip Code:97015-5331
Mailing Address - Country:US
Mailing Address - Phone:360-500-5274
Mailing Address - Fax:
Practice Address - Street 1:970 NW EASTMAN PKWY
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-5533
Practice Address - Country:US
Practice Address - Phone:503-666-7460
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-12
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR4676152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist