Provider Demographics
NPI:1699404905
Name:RICHARDSON, DOUGLAS LAMONT
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:LAMONT
Last Name:RICHARDSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2709 CHURCH ST STE A
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:SC
Mailing Address - Zip Code:29526-4440
Mailing Address - Country:US
Mailing Address - Phone:843-365-0739
Mailing Address - Fax:843-365-0751
Practice Address - Street 1:2709 CHURCH ST STE A
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:SC
Practice Address - Zip Code:29526-4440
Practice Address - Country:US
Practice Address - Phone:843-365-0739
Practice Address - Fax:843-365-0751
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-10
Last Update Date:2022-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician