Provider Demographics
NPI:1184611766
Name:RICHMOND, RONALD L (OD)
Entity type:Individual
Prefix:DR
First Name:RONALD
Middle Name:L
Last Name:RICHMOND
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 1:8309 N KNOXVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61615-2170
Mailing Address - Country:US
Mailing Address - Phone:309-693-9540
Mailing Address - Fax:309-693-9542
Practice Address - Street 1:1700 PARKWAY PLAZA DR
Practice Address - Street 2:4
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761-2896
Practice Address - Country:US
Practice Address - Phone:309-454-2233
Practice Address - Fax:309-454-2210
Is Sole Proprietor?:No
Enumeration Date:2005-09-29
Last Update Date:2014-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046007338152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046007338Medicaid
IL7215175OtherBCBS
IL410038950OtherMEDICARE RAILROAD
ILT39050Medicare UPIN
IL046007338Medicaid
ILK04669Medicare PIN