Provider Demographics
NPI:1659447332
Name:DOTTERER, RICHARD TRAVIS JR (OD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:TRAVIS
Last Name:DOTTERER
Suffix:JR
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 1:4210 W ESTATE CT
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47404-9521
Mailing Address - Country:US
Mailing Address - Phone:812-320-0636
Mailing Address - Fax:
Practice Address - Street 1:410 GRAND VALLEY BLVD
Practice Address - Street 2:
Practice Address - City:MARTINSVILLE
Practice Address - State:IN
Practice Address - Zip Code:46151
Practice Address - Country:US
Practice Address - Phone:812-320-0636
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-27
Last Update Date:2020-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18001698B152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100195280BMedicaid
610300Medicare ID - Type Unspecified
IN100195280BMedicaid