Provider Demographics
NPI:1295721520
Name:ABBOTT, RICHARD J (OD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:J
Last Name:ABBOTT
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 1:929 BUSINESS PARK DR
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49686-8683
Mailing Address - Country:US
Mailing Address - Phone:231-947-6246
Mailing Address - Fax:231-947-8864
Practice Address - Street 1:929 BUSINESS PARK DR
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49686-8683
Practice Address - Country:US
Practice Address - Phone:231-947-6246
Practice Address - Fax:231-947-8864
Is Sole Proprietor?:No
Enumeration Date:2005-09-22
Last Update Date:2009-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002395152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3248321Medicaid
MI3248321Medicaid
MI0424860005Medicare NSC