Provider Demographics
NPI:1760515316
Name:RICHARDSON, JOHN MARCEAU (OD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:MARCEAU
Last Name:RICHARDSON
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 1:3802 POPLAR DR
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64804-4055
Mailing Address - Country:US
Mailing Address - Phone:417-626-7850
Mailing Address - Fax:
Practice Address - Street 1:121 PETER PAN RD
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:KS
Practice Address - Zip Code:67301-7307
Practice Address - Country:US
Practice Address - Phone:620-235-9021
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS954-2152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS778OtherPREFERRED HEALTH
KS45138OtherSPECTERA
KS42128Medicaid
KS778OtherPREFERRED HEALTH
005311Medicare ID - Type Unspecified