Provider Demographics
NPI:1598929796
Name:RICHARDS, SHAWN CHARLES (MD)
Entity Type:Individual
Prefix:DR
First Name:SHAWN
Middle Name:CHARLES
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 1:2500 W A ST
Mailing Address - Street 2:SUITE 202
Mailing Address - City:MOSCOW
Mailing Address - State:ID
Mailing Address - Zip Code:83843-6000
Mailing Address - Country:US
Mailing Address - Phone:208-882-4662
Mailing Address - Fax:
Practice Address - Street 1:2500 W A ST
Practice Address - Street 2:SUITE 202
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83843-6000
Practice Address - Country:US
Practice Address - Phone:208-882-4662
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-16
Last Update Date:2016-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO49995207W00000X
WAMD60292777207W00000X
IDM-12529207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAP01110201OtherRR MEDICARE
WA0299990OtherL&I
WA1598929796Medicaid
WAG8920350Medicare PIN
WAG8912416Medicare PIN