Provider Demographics
NPI:1801593223
Name:RICHARDSON, CHARLES DUANE (LDO)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:DUANE
Last Name:RICHARDSON
Suffix:
Gender:M
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3750 W MARKET ST UNIT I
Mailing Address - Street 2:
Mailing Address - City:FAIRLAWN
Mailing Address - State:OH
Mailing Address - Zip Code:44333-2474
Mailing Address - Country:US
Mailing Address - Phone:330-665-4268
Mailing Address - Fax:330-666-8922
Practice Address - Street 1:3750 W MARKET ST
Practice Address - Street 2:
Practice Address - City:FAIRLAWN
Practice Address - State:OH
Practice Address - Zip Code:44333-4804
Practice Address - Country:US
Practice Address - Phone:330-665-4268
Practice Address - Fax:330-666-8922
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-15
Last Update Date:2023-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOP017202S156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician