Provider Demographics
NPI:1447232806
Name:RICHARDS, SCOTT C (MD)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:C
Last Name:RICHARDS
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:PO BOX 549
Mailing Address - Street 2:
Mailing Address - City:WABASH
Mailing Address - State:IN
Mailing Address - Zip Code:46992-0549
Mailing Address - Country:US
Mailing Address - Phone:260-569-9550
Mailing Address - Fax:260-569-0760
Practice Address - Street 1:7747 W JEFFERSON BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804
Practice Address - Country:US
Practice Address - Phone:260-459-8444
Practice Address - Fax:260-459-8443
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2018-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01071002A207WX0107X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201071420Medicaid
IN160450023Medicare PIN
IN201071420Medicaid
IN669220010Medicare PIN
INP01117359Medicare PIN
UT000010040Medicare ID - Type Unspecified
INM400074799Medicare PIN
IN452570027Medicare PIN
UT0515900001Medicare NSC