Provider Demographics
NPI:1730103623
Name:RICHARDSON, DAPHNE L (OD)
Entity Type:Individual
Prefix:
First Name:DAPHNE
Middle Name:L
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4220A MAGAZINE
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70115
Mailing Address - Country:US
Mailing Address - Phone:504-896-7661
Mailing Address - Fax:504-896-7656
Practice Address - Street 1:4220 MAGAZINE ST # A
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70115-2735
Practice Address - Country:US
Practice Address - Phone:504-896-7661
Practice Address - Fax:504-896-7656
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2013-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1353-487T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
4B271OtherMEDICARE PTAN
LA1145157Medicaid
LA5CW98Medicare PIN
LA91715Medicare UPIN
LA1145157Medicaid
4B271OtherMEDICARE PTAN
LA4P832DR86Medicare PIN