Provider Demographics
NPI:1811904618
Name:MADDEN, RICHARD B (OD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:B
Last Name:MADDEN
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 1:4076 NEELY ROAD
Mailing Address - Street 2:
Mailing Address - City:FORT WAINWRIGHT
Mailing Address - State:AK
Mailing Address - Zip Code:99703
Mailing Address - Country:US
Mailing Address - Phone:907-361-6028
Mailing Address - Fax:907-361-4847
Practice Address - Street 1:4076 NEELY ROAD
Practice Address - Street 2:
Practice Address - City:FORT WAINWRIGHT
Practice Address - State:AK
Practice Address - Zip Code:99703
Practice Address - Country:US
Practice Address - Phone:907-361-6028
Practice Address - Fax:907-361-4847
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-02
Last Update Date:2024-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1159152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100761570AMedicaid
OK0469490001Medicare NSC