Provider Demographics
NPI:1093710113
Name:RICHTER, JON KEVIN (MD)
Entity type:Individual
Prefix:
First Name:JON
Middle Name:KEVIN
Last Name:RICHTER
Suffix:
Gender:M
Credentials:MD
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 505673
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63150-5673
Mailing Address - Country:US
Mailing Address - Phone:417-730-6430
Mailing Address - Fax:417-269-7567
Practice Address - Street 1:5136 STATE HIGHWAY 265
Practice Address - Street 2:
Practice Address - City:BRANSON
Practice Address - State:MO
Practice Address - Zip Code:65616-9099
Practice Address - Country:US
Practice Address - Phone:417-338-0960
Practice Address - Fax:417-338-0968
Is Sole Proprietor?:No
Enumeration Date:2005-06-15
Last Update Date:2024-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2024021907207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR128865001Medicaid
AR5J965Medicare ID - Type Unspecified
AR128865001Medicaid