Provider Demographics
NPI:1568570117
Name:RICHARDSON, CHARLES DAVID (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:DAVID
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 1:100 HOSPITAL DR W
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39402-1334
Mailing Address - Country:US
Mailing Address - Phone:601-268-5910
Mailing Address - Fax:601-264-0659
Practice Address - Street 1:100 HOSPITAL DR W
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402-1334
Practice Address - Country:US
Practice Address - Phone:601-268-5910
Practice Address - Fax:601-264-0659
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS10012207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS10012OtherMEDICAL LICENSE
MS00016828Medicaid
MSAR2216388OtherDEA NUMBER
MS10012OtherMEDICAL LICENSE
MSD73560Medicare UPIN