Provider Demographics
NPI:1164512257
Name:CROSS, RICHARD (OD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:
Last Name:CROSS
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 1:5305 SPINE RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80301-3331
Mailing Address - Country:US
Mailing Address - Phone:303-530-2020
Mailing Address - Fax:303-530-1072
Practice Address - Street 1:5305 SPINE RD
Practice Address - Street 2:SUITE B
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80301-3331
Practice Address - Country:US
Practice Address - Phone:303-530-2020
Practice Address - Fax:303-530-1072
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2009-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1436152W00000X, 152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
COC43423Medicare PIN
COC43423Medicare ID - Type UnspecifiedMEDICARE