Provider Demographics
NPI:1033126628
Name:KIMMICH, RICHARD HERMAN (OD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:HERMAN
Last Name:KIMMICH
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 1:1011 STONEBRIDGE PKWY
Mailing Address - Street 2:SUITE 106
Mailing Address - City:WATKINSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30677-6011
Mailing Address - Country:US
Mailing Address - Phone:706-310-5050
Mailing Address - Fax:706-310-5053
Practice Address - Street 1:1011 STONEBRIDGE PKWY
Practice Address - Street 2:SUITE 106
Practice Address - City:WATKINSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30677-6011
Practice Address - Country:US
Practice Address - Phone:706-310-5050
Practice Address - Fax:706-310-5053
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2012-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT000930152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000248278CMedicaid
GA41ZCFPPMedicare ID - Type Unspecified
GA000248278CMedicaid