Healthcare Provider Details

I. General information

NPI: 1265614309
Provider Name (Legal Business Name): TRAVIS D RICHARDSON, DO, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2007
Last Update Date: 11/30/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 W 6TH ST
MOUNTAIN HOME AR
72653-3409
US

IV. Provider business mailing address

PO BOX 1677
MOUNTAIN HOME AR
72654-1677
US

V. Phone/Fax

Practice location:
  • Phone: 870-424-4507
  • Fax: 870-425-4546
Mailing address:
  • Phone: 870-424-4507
  • Fax: 870-425-4546

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License NumberE4201
License Number StateAR

VIII. Authorized Official

Name: DR. TRAVIS DALE RICHARDSON
Title or Position: PRESIDENT
Credential: DO
Phone: 870-424-4507