Provider Demographics
NPI:1720135882
Name:FRY, RICHARD E (OD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:E
Last Name:FRY
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 1:110 S THOMAS ST
Mailing Address - Street 2:
Mailing Address - City:BEULAVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28518-8810
Mailing Address - Country:US
Mailing Address - Phone:910-298-3001
Mailing Address - Fax:910-298-8149
Practice Address - Street 1:110 S THOMAS ST
Practice Address - Street 2:
Practice Address - City:BEULAVILLE
Practice Address - State:NC
Practice Address - Zip Code:28518-8810
Practice Address - Country:US
Practice Address - Phone:910-298-3001
Practice Address - Fax:910-298-8149
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2012-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1189152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC09296OtherBLUE CROSS AND BLUE SHIELD OF NORTH CAROLINA
NC8909296Medicaid
NC09296OtherBLUE CROSS AND BLUE SHIELD OF NORTH CAROLINA
NCNC5079A841Medicare PIN