Provider Demographics
NPI:1396178943
Name:RICHARDSON, OWEN S (MD)
Entity Type:Individual
Prefix:
First Name:OWEN
Middle Name:S
Last Name:RICHARDSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 751069
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1069
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:517 MOYE BLVD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-2849
Practice Address - Country:US
Practice Address - Phone:252-847-4299
Practice Address - Fax:252-847-8208
Is Sole Proprietor?:No
Enumeration Date:2013-08-19
Last Update Date:2024-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCRTL228095208600000X
NC2023-00404208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery