Provider Demographics
NPI:1821277286
Name:PEACH, RICHARD J (OD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:J
Last Name:PEACH
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 1:800 MACARTHUR BLVD
Mailing Address - Street 2:STE 10
Mailing Address - City:MUNSTER
Mailing Address - State:IN
Mailing Address - Zip Code:46321-2917
Mailing Address - Country:US
Mailing Address - Phone:219-922-8017
Mailing Address - Fax:
Practice Address - Street 1:800 MACARTHUR BLVD
Practice Address - Street 2:SUITE 10
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-2917
Practice Address - Country:US
Practice Address - Phone:219-836-5326
Practice Address - Fax:219-836-5326
Is Sole Proprietor?:No
Enumeration Date:2007-11-01
Last Update Date:2017-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18001668A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN0509220001OtherDMERC
IN0509220001OtherDMERC
INU09494Medicare UPIN
IN0509220001Medicare NSC