Provider Demographics
NPI:1386697746
Name:RICH, DAVID LEE (OD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:LEE
Last Name:RICH
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 1:4523 NATIONAL RD E
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:IN
Mailing Address - Zip Code:47374-3731
Mailing Address - Country:US
Mailing Address - Phone:765-962-3800
Mailing Address - Fax:
Practice Address - Street 1:4523 NATIONAL RD E
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:IN
Practice Address - Zip Code:47374-3731
Practice Address - Country:US
Practice Address - Phone:765-962-3800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-18
Last Update Date:2024-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT001956152W00000X
IN18003085152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA156200053AMedicaid
GA156200053AMedicaid
GA202I181399Medicare PIN