Provider Demographics
NPI:1679644124
Name:RICHARDS, CHARLES A (OD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:A
Last Name:RICHARDS
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 1:17151 MAIN ST STE C
Mailing Address - Street 2:
Mailing Address - City:HESPERIA
Mailing Address - State:CA
Mailing Address - Zip Code:92345-6004
Mailing Address - Country:US
Mailing Address - Phone:760-244-4904
Mailing Address - Fax:760-244-7804
Practice Address - Street 1:17151 MAIN ST STE C
Practice Address - Street 2:
Practice Address - City:HESPERIA
Practice Address - State:CA
Practice Address - Zip Code:92345-6004
Practice Address - Country:US
Practice Address - Phone:760-244-4904
Practice Address - Fax:760-244-7804
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-13
Last Update Date:2014-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT6330TPL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0063300Medicaid
CAT10292Medicare UPIN
CASD0063300Medicaid
CASD0063300Medicare ID - Type Unspecified
CA0513240001Medicare NSC