Provider Demographics
NPI:1205992088
Name:KJOME, RICHARD A (OD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:A
Last Name:KJOME
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:PO BOX 238
Mailing Address - Street 2:
Mailing Address - City:ANTIGO
Mailing Address - State:WI
Mailing Address - Zip Code:54409-0238
Mailing Address - Country:US
Mailing Address - Phone:715-623-2180
Mailing Address - Fax:
Practice Address - Street 1:714 3RD AVE
Practice Address - Street 2:
Practice Address - City:ANTIGO
Practice Address - State:WI
Practice Address - Zip Code:54409-2044
Practice Address - Country:US
Practice Address - Phone:715-623-2180
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1477-035152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38563700Medicaid
WI38563700Medicaid