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 1:408 ORCHARD DR
Mailing Address - Street 2:
Mailing Address - City:BERRYVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72616-4320
Mailing Address - Country:US
Mailing Address - Phone:870-423-2320
Mailing Address - Fax:870-423-7431
Practice Address - Street 1:206 S. MAIN
Practice Address - Street 2:
Practice Address - City:BERRYVILLE
Practice Address - State:AR
Practice Address - Zip Code:72616-4320
Practice Address - Country:US
Practice Address - Phone:870-423-2320
Practice Address - Fax:870-423-7431
Is Sole Proprietor?:No
Enumeration Date:2005-06-15
Last Update Date:2022-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE0607207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR128865001Medicaid
AR5J965Medicare ID - Type Unspecified
AR128865001Medicaid