Provider Demographics
NPI:1801895438
Name:RICHARDSON, STEPHEN M (OD)
Entity type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:M
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 1:430 NEAL ST
Mailing Address - Street 2:
Mailing Address - City:COOKEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38501-0916
Mailing Address - Country:US
Mailing Address - Phone:931-528-6411
Mailing Address - Fax:931-372-0380
Practice Address - Street 1:430 NEAL ST
Practice Address - Street 2:
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38501-0916
Practice Address - Country:US
Practice Address - Phone:931-528-6411
Practice Address - Fax:931-372-0380
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-15
Last Update Date:2023-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNODT-1155152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
0095470OtherBCBS TN
TN3596618Medicaid
TN3596618Medicaid
TN1231940001Medicare PIN