Provider Demographics
NPI:1609973122
Name:SHRODER, RICHARD LEE (OD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:LEE
Last Name:SHRODER
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 1:899 N BROADWAY
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:OH
Mailing Address - Zip Code:45036-1361
Mailing Address - Country:US
Mailing Address - Phone:513-932-1976
Mailing Address - Fax:513-932-1976
Practice Address - Street 1:899 N BROADWAY
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:OH
Practice Address - Zip Code:45036-1361
Practice Address - Country:US
Practice Address - Phone:513-932-1976
Practice Address - Fax:513-932-1976
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2696T741152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000003878OtherANTHEM
OH000000249581OtherANTHEM
OH0345630001Medicare NSC
OH000000003878OtherANTHEM
OH000000249581OtherANTHEM