Provider Demographics
NPI:1942358320
Name:PACKARD, RICHARD VANDYKE (OD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:VANDYKE
Last Name:PACKARD
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 1:74927 US HIGHWAY 111
Mailing Address - Street 2:
Mailing Address - City:INDIAN WELLS
Mailing Address - State:CA
Mailing Address - Zip Code:92210-7136
Mailing Address - Country:US
Mailing Address - Phone:760-568-2340
Mailing Address - Fax:866-529-1713
Practice Address - Street 1:74927 US HIGHWAY 111
Practice Address - Street 2:
Practice Address - City:INDIAN WELLS
Practice Address - State:CA
Practice Address - Zip Code:92210
Practice Address - Country:US
Practice Address - Phone:760-568-2340
Practice Address - Fax:866-529-1713
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2019-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9332TPA152WC0802X
CA9332152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU12143Medicare UPIN