Provider Demographics
NPI:1639327000
Name:RICHARDSON, GARY C (O,D)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:C
Last Name:RICHARDSON
Suffix:
Gender:M
Credentials:O,D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:404 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NORTH LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72114-5328
Mailing Address - Country:US
Mailing Address - Phone:501-374-3335
Mailing Address - Fax:501-374-3369
Practice Address - Street 1:404 MAIN ST
Practice Address - Street 2:
Practice Address - City:NORTH LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72114-5328
Practice Address - Country:US
Practice Address - Phone:501-374-3335
Practice Address - Fax:501-374-3369
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-28
Last Update Date:2008-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2164152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist