Provider Demographics
NPI:1487779062
Name:VILLANE, RICHARD PAUL (OD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:PAUL
Last Name:VILLANE
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 1:7930 WOLF RIVER BLVD
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38138-1725
Mailing Address - Country:US
Mailing Address - Phone:901-755-7887
Mailing Address - Fax:901-755-0266
Practice Address - Street 1:7930 WOLF RIVER BLVD
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:TN
Practice Address - Zip Code:38138-1725
Practice Address - Country:US
Practice Address - Phone:901-755-7887
Practice Address - Fax:901-755-0266
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2009-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNT1076152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3596533Medicare PIN
TN1055420001Medicare NSC