Provider Demographics
NPI:1922009836
Name:RICHARDSON, BRAD C (OD)
Entity Type:Individual
Prefix:DR
First Name:BRAD
Middle Name:C
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:PO BOX 38
Mailing Address - Street 2:
Mailing Address - City:FOREST GROVE
Mailing Address - State:OR
Mailing Address - Zip Code:97116-0038
Mailing Address - Country:US
Mailing Address - Phone:503-357-2020
Mailing Address - Fax:
Practice Address - Street 1:2804 19TH AVE
Practice Address - Street 2:
Practice Address - City:FOREST GROVE
Practice Address - State:OR
Practice Address - Zip Code:97116-2625
Practice Address - Country:US
Practice Address - Phone:503-357-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2012-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1942AT ACTIVE152W00000X
ORHAS-P-470158237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR0000PHFRXMedicare ID - Type Unspecified
OR198937Medicare ID - Type Unspecified
ORU20513Medicare UPIN