Provider Demographics
NPI:1497812242
Name:KERN, RICHARD CHARLES (OD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:CHARLES
Last Name:KERN
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 1:4408 N KNOXVILLE AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-6084
Mailing Address - Country:US
Mailing Address - Phone:309-682-6214
Mailing Address - Fax:309-682-6236
Practice Address - Street 1:4408 N KNOXVILLE AVE
Practice Address - Street 2:SUITE C
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-6084
Practice Address - Country:US
Practice Address - Phone:309-682-6214
Practice Address - Fax:309-682-6236
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2008-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0467198152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046007198Medicaid
ILT35739Medicare UPIN
IL0152870001Medicare NSC
IL046007198Medicaid