Basic Information
| Provider Information | |||||||||
| NPI: | 1184611766 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RICHMOND | ||||||||
| FirstName: | RONALD | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8309 N KNOXVILLE AVE | ||||||||
| Address2: | |||||||||
| City: | PEORIA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 616152170 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3096939540 | ||||||||
| FaxNumber: | 3096939542 | ||||||||
| Practice Location | |||||||||
| Address1: | 1700 PARKWAY PLAZA DR | ||||||||
| Address2: | 4 | ||||||||
| City: | NORMAL | ||||||||
| State: | IL | ||||||||
| PostalCode: | 617612896 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3094542233 | ||||||||
| FaxNumber: | 3094542210 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/29/2005 | ||||||||
| LastUpdateDate: | 01/07/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 046007338 | IL | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 046007338 | 05 | IL | MEDICAID | 7215175 | 01 | IL | BCBS | OTHER | 410038950 | 01 | IL | MEDICARE RAILROAD | OTHER |