Provider Demographics
NPI:1285975094
Name:RICHARDSON, NICHOLAS THOMAS (OD)
Entity type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:THOMAS
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:PO BOX 418
Mailing Address - Street 2:
Mailing Address - City:CALEDONIA
Mailing Address - State:MS
Mailing Address - Zip Code:39740-0418
Mailing Address - Country:US
Mailing Address - Phone:662-241-9661
Mailing Address - Fax:662-241-9663
Practice Address - Street 1:9692 WOLFE RD
Practice Address - Street 2:
Practice Address - City:CALEDONIA
Practice Address - State:MS
Practice Address - Zip Code:39740-9223
Practice Address - Country:US
Practice Address - Phone:662-241-9661
Practice Address - Fax:662-241-9663
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-05
Last Update Date:2024-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS871152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist