Provider Demographics
NPI:1477809697
Name:RICHARDSON, DEREK ALEXANDER (OD)
Entity Type:Individual
Prefix:DR
First Name:DEREK
Middle Name:ALEXANDER
Last Name:RICHARDSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4110 ROCKY FORK TER
Mailing Address - Street 2:
Mailing Address - City:ELLENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34222-7233
Mailing Address - Country:US
Mailing Address - Phone:407-454-1164
Mailing Address - Fax:
Practice Address - Street 1:10000 BAY PINES BLVD
Practice Address - Street 2:
Practice Address - City:BAY PINES
Practice Address - State:FL
Practice Address - Zip Code:33744
Practice Address - Country:US
Practice Address - Phone:727-398-6661
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-25
Last Update Date:2018-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GUOPC5098152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist