Provider Demographics
NPI:1659638799
Name:SCHULTZ, RICHARD OTTO
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:OTTO
Last Name:SCHULTZ
Suffix:
Gender:M
Credentials:
Other - Prefix:DR
Other - First Name:RICHARD
Other - Middle Name:OTTO
Other - Last Name:SCHULTZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:4487 GRANNY SMITH CT
Mailing Address - Street 2:
Mailing Address - City:EGG HARBOR
Mailing Address - State:WI
Mailing Address - Zip Code:54209-9559
Mailing Address - Country:US
Mailing Address - Phone:920-868-5021
Mailing Address - Fax:920-868-5021
Practice Address - Street 1:4487 GRANNY SMITH CT
Practice Address - Street 2:
Practice Address - City:EGG HARBOR
Practice Address - State:WI
Practice Address - Zip Code:54209-9559
Practice Address - Country:US
Practice Address - Phone:920-868-5021
Practice Address - Fax:920-868-5021
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-13
Last Update Date:2012-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI13963-20174400000X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology