Provider Demographics
NPI:1265614309
Name:TRAVIS D RICHARDSON, DO, PLLC
Entity type:Organization
Organization Name:TRAVIS D RICHARDSON, DO, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TRAVIS
Authorized Official - Middle Name:DALE
Authorized Official - Last Name:RICHARDSON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:870-424-4507
Mailing Address - Street 1:PO BOX 1677
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:AR
Mailing Address - Zip Code:72654-1677
Mailing Address - Country:US
Mailing Address - Phone:870-424-4507
Mailing Address - Fax:870-425-4546
Practice Address - Street 1:555 W 6TH ST
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME
Practice Address - State:AR
Practice Address - Zip Code:72653-3409
Practice Address - Country:US
Practice Address - Phone:870-424-4507
Practice Address - Fax:870-425-4546
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-30
Last Update Date:2007-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE4201207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the SpineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5939000001Medicare NSC