Provider Demographics
NPI:1891782215
Name:MARGERUM, RICHARD EUGENE (OD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:EUGENE
Last Name:MARGERUM
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 1:326 N MAIN ST
Mailing Address - Street 2:PO BOX 747
Mailing Address - City:MOSCOW
Mailing Address - State:PA
Mailing Address - Zip Code:18444-9155
Mailing Address - Country:US
Mailing Address - Phone:570-842-2400
Mailing Address - Fax:
Practice Address - Street 1:326 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MOSCOW
Practice Address - State:PA
Practice Address - Zip Code:18444-9155
Practice Address - Country:US
Practice Address - Phone:570-842-2400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-30
Last Update Date:2010-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG000593152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAMA288378Medicaid
PAMA288378Medicaid