Healthcare Provider Details

I. General information

NPI: 1205703329
Provider Name (Legal Business Name): WEST VIRGINIA RETINA INSTITUTE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/22/2025
Last Update Date: 12/03/2025
Certification Date: 12/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 LAIDLEY ST STE 208
CHARLESTON WV
25301-1614
US

IV. Provider business mailing address

PO BOX 70100
CHARLESTON WV
25301-0100
US

V. Phone/Fax

Practice location:
  • Phone: 304-935-0014
  • Fax:
Mailing address:
  • Phone: 229-402-5869
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207WX0107X
TaxonomyRetina Specialist (Ophthalmology) Physician
License Number
License Number State

VIII. Authorized Official

Name: DANIEL RUSSELL RICHARDSON
Title or Position: MEMBER
Credential: MD
Phone: 229-402-5869