Healthcare Provider Details

I. General information

NPI: 1346924347
Provider Name (Legal Business Name): MATTHEW CRAWFORD RICHARDSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2023
Last Update Date: 06/12/2023
Certification Date: 06/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

970 NW EASTMAN PKWY
GRESHAM OR
97030-5533
US

IV. Provider business mailing address

11510 SE SUNNYSIDE RD APT 16
CLACKAMAS OR
97015-5331
US

V. Phone/Fax

Practice location:
  • Phone: 503-666-7460
  • Fax:
Mailing address:
  • Phone: 360-500-5274
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4676
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: