Provider Demographics
NPI:1528022035
Name:VANOVER, RICHARD (OD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:VANOVER
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 1:3133 W MARCH LN
Mailing Address - Street 2:SUITE 2020
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95219-2336
Mailing Address - Country:US
Mailing Address - Phone:209-951-0820
Mailing Address - Fax:209-951-2348
Practice Address - Street 1:3133 W MARCH LN
Practice Address - Street 2:SUITE 2020
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95219-2336
Practice Address - Country:US
Practice Address - Phone:209-951-0820
Practice Address - Fax:209-951-2348
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-12
Last Update Date:2015-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9667T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0096670Medicaid
CA0694800001OtherDMERC
CA0694800001OtherDMERC
CASD0096670Medicaid