Provider Demographics
NPI:1578877056
Name:RICHARDSON, ELI (OD)
Entity Type:Individual
Prefix:
First Name:ELI
Middle Name:
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:PO BOX 847
Mailing Address - Street 2:
Mailing Address - City:FOREST GROVE
Mailing Address - State:OR
Mailing Address - Zip Code:97116-0847
Mailing Address - Country:US
Mailing Address - Phone:503-357-2020
Mailing Address - Fax:503-357-6995
Practice Address - Street 1:2804 19TH AVE
Practice Address - Street 2:
Practice Address - City:FOREST GROVE
Practice Address - State:OR
Practice Address - Zip Code:97116-2625
Practice Address - Country:US
Practice Address - Phone:503-357-2020
Practice Address - Fax:503-357-6995
Is Sole Proprietor?:No
Enumeration Date:2010-07-27
Last Update Date:2012-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3381ATI152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist