Provider Demographics
NPI:1841309713
Name:NEWCOMB, RICHARD LYNN (OD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:LYNN
Last Name:NEWCOMB
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 1:1411 N JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:MO
Mailing Address - Zip Code:64633-1945
Mailing Address - Country:US
Mailing Address - Phone:660-542-2715
Mailing Address - Fax:660-542-2227
Practice Address - Street 1:1411 N JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:MO
Practice Address - Zip Code:64633-1945
Practice Address - Country:US
Practice Address - Phone:660-542-2715
Practice Address - Fax:660-542-2227
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2015-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOT02635152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
410029304OtherRAILROAD MEDICARE
13839018OtherBLUE CROSS BLUE SHIELD
MO160226OtherBLUE CROSS BLUE SHIELD
MO312171705Medicaid
MO312171705Medicaid
0007023Medicare ID - Type Unspecified
MO4388510001Medicare NSC
T42452Medicare UPIN