=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346924347
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MATTHEW CRAWFORD RICHARDSON
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/12/2023
-----------------------------------------------------
Last Update Date | 06/12/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 970 NW EASTMAN PKWY
-----------------------------------------------------
City | GRESHAM
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97030-5533
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-666-7460
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11510 SE SUNNYSIDE RD APT 16
-----------------------------------------------------
City | CLACKAMAS
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97015-5331
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-500-5274
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 4676
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------