Provider Demographics
NPI:1003904004
Name:RICHARDSON, DONALD L (OD)
Entity type:Individual
Prefix:DR
First Name:DONALD
Middle Name:L
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 1:246 POPLAR AVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:SOMERSET
Mailing Address - State:KY
Mailing Address - Zip Code:42503-1701
Mailing Address - Country:US
Mailing Address - Phone:606-679-5588
Mailing Address - Fax:606-677-9394
Practice Address - Street 1:246 POPLAR AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:SOMERSET
Practice Address - State:KY
Practice Address - Zip Code:42503-1701
Practice Address - Country:US
Practice Address - Phone:606-679-5588
Practice Address - Fax:606-677-9394
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2015-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY991DTKY152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY9213501OtherMEDICARE
KY77009918Medicaid
KY77009918Medicaid