Provider Demographics
NPI:1659364909
Name:SKOTOWSKI, RICHARD
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:SKOTOWSKI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 GLENN ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IA
Mailing Address - Zip Code:52314-0189
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:202 GLENN ST SE
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IA
Practice Address - Zip Code:52314-1588
Practice Address - Country:US
Practice Address - Phone:319-895-8888
Practice Address - Fax:319-895-8889
Is Sole Proprietor?:No
Enumeration Date:2005-08-23
Last Update Date:2008-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA1805152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA22404OtherBLUE CROSS BLUE SHIELD
IA0030502Medicaid
T01275Medicare UPIN
IA20796Medicare ID - Type Unspecified
IA0030502Medicaid
IA22404OtherBLUE CROSS BLUE SHIELD