Provider Demographics
NPI:1700974268
Name:SALISBURY, RICHARD (OD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:SALISBURY
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 1473
Mailing Address - Street 2:
Mailing Address - City:MARTIN
Mailing Address - State:KY
Mailing Address - Zip Code:41649-1473
Mailing Address - Country:US
Mailing Address - Phone:606-285-0005
Mailing Address - Fax:606-285-0007
Practice Address - Street 1:10870 MAIN STREET
Practice Address - Street 2:
Practice Address - City:MARTIN
Practice Address - State:KY
Practice Address - Zip Code:41649-7999
Practice Address - Country:US
Practice Address - Phone:606-285-0005
Practice Address - Fax:606-285-0007
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2016-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1194DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY77011948Medicaid
KY77011948Medicaid
KY1319980001Medicare NSC
KY410041838Medicare PIN