Provider Demographics
NPI:1396144341
Name:TRAVIS D. RICHARDSON, D.O. PLC
Entity type:Organization
Organization Name:TRAVIS D. RICHARDSON, D.O. PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR OF OSTEOPATHIC MEDICINE
Authorized Official - Prefix:DR
Authorized Official - First Name:TRAVIS
Authorized Official - Middle Name:D
Authorized Official - Last Name:RICHARDSON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:870-239-8102
Mailing Address - Street 1:1507 LINWOOD DR STE A
Mailing Address - Street 2:
Mailing Address - City:PARAGOULD
Mailing Address - State:AR
Mailing Address - Zip Code:72450-5818
Mailing Address - Country:US
Mailing Address - Phone:870-239-8102
Mailing Address - Fax:870-239-8105
Practice Address - Street 1:1507 LINWOOD DR STE A
Practice Address - Street 2:
Practice Address - City:PARAGOULD
Practice Address - State:AR
Practice Address - Zip Code:72450-5818
Practice Address - Country:US
Practice Address - Phone:870-239-8102
Practice Address - Fax:870-239-8105
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-15
Last Update Date:2020-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332BX2000X
ARE4201207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the SpineGroup - Multi-Specialty
No332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & SuppliesGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR219624004Medicaid
AR238889716Medicaid