Provider Demographics
NPI:1487148243
Name:RICHARDSON, COLE MCKEE (DO)
Entity type:Individual
Prefix:
First Name:COLE
Middle Name:MCKEE
Last Name:RICHARDSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 MILLSAPS DR STE B
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39402-1587
Mailing Address - Country:US
Mailing Address - Phone:601-255-0736
Mailing Address - Fax:
Practice Address - Street 1:109 MILLSAPS DR
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402-1587
Practice Address - Country:US
Practice Address - Phone:601-818-2957
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-15
Last Update Date:2024-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5151009600207W00000X
MS33128207WX0107X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5101024179Medicaid