Provider Demographics
NPI:1376570838
Name:RICHARDS, SHELLEY M (OD)
Entity Type:Individual
Prefix:
First Name:SHELLEY
Middle Name:M
Last Name:RICHARDS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:445 W POPLAR ST
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95203-2426
Mailing Address - Country:US
Mailing Address - Phone:209-465-5933
Mailing Address - Fax:209-465-2562
Practice Address - Street 1:445 W POPLAR ST
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95203-2426
Practice Address - Country:US
Practice Address - Phone:209-465-5933
Practice Address - Fax:209-465-2562
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2012-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT12929152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA3161936Medicaid
CA3161936Medicaid
CASD0129290Medicare ID - Type Unspecified