Provider Demographics
NPI:1801000732
Name:PALACIOS, RICHARD (OD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:PALACIOS
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 1:9301 TAMPA AVE UNIT 62
Mailing Address - Street 2:
Mailing Address - City:NORTHRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:91324-5656
Mailing Address - Country:US
Mailing Address - Phone:818-885-7300
Mailing Address - Fax:
Practice Address - Street 1:9301 TAMPA AVE
Practice Address - Street 2:LENSCRAFTER IN MACYS
Practice Address - City:NORTHRIDGE
Practice Address - State:CA
Practice Address - Zip Code:91324-5656
Practice Address - Country:US
Practice Address - Phone:818-341-3760
Practice Address - Fax:818-341-3745
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYVUT006119152W00000X
CAOPT12213152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U80625Medicare UPIN