Provider Demographics
NPI:1629428701
Name:RICHARD, ALYSE (MD)
Entity Type:Individual
Prefix:
First Name:ALYSE
Middle Name:
Last Name:RICHARD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51 STATE RD
Mailing Address - Street 2:
Mailing Address - City:DARTMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02747-3319
Mailing Address - Country:US
Mailing Address - Phone:508-994-1400
Mailing Address - Fax:508-910-2212
Practice Address - Street 1:51 STATE RD
Practice Address - Street 2:
Practice Address - City:DARTMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02747-3319
Practice Address - Country:US
Practice Address - Phone:508-994-1400
Practice Address - Fax:508-910-2212
Is Sole Proprietor?:No
Enumeration Date:2016-06-20
Last Update Date:2022-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA282304207W00000X, 207WX0107X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina Specialist
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110160033AMedicaid