Provider Demographics
NPI:1720358641
Name:RICHARDSON, BRETT (OD)
Entity Type:Individual
Prefix:
First Name:BRETT
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 1:31 W BROOKHAVEN DR
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:UT
Mailing Address - Zip Code:84780-5004
Mailing Address - Country:US
Mailing Address - Phone:360-991-9548
Mailing Address - Fax:
Practice Address - Street 1:1120 W PIONEER BLVD
Practice Address - Street 2:
Practice Address - City:MESQUITE
Practice Address - State:NV
Practice Address - Zip Code:89027
Practice Address - Country:US
Practice Address - Phone:360-991-9548
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-10
Last Update Date:2021-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10370059-9934152W00000X
NV918152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist