Provider Demographics
NPI:1710964309
Name:NUTT, RICHARD LANE (OD)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:LANE
Last Name:NUTT
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 1:1111 E CAMBRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:BOLIVAR
Mailing Address - State:MO
Mailing Address - Zip Code:65613-3500
Mailing Address - Country:US
Mailing Address - Phone:417-326-6001
Mailing Address - Fax:417-326-6002
Practice Address - Street 1:1111 E CAMBRIDGE ST
Practice Address - Street 2:
Practice Address - City:BOLIVAR
Practice Address - State:MO
Practice Address - Zip Code:65613-3500
Practice Address - Country:US
Practice Address - Phone:417-326-6001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-27
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOT02491152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1710964309Medicaid
MO0442260001Medicare NSC