Provider Demographics
NPI:1881623916
Name:REICHERT, RICHARD W (MD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:W
Last Name:REICHERT
Suffix:
Gender:M
Credentials:MD
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 489
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32056-0489
Mailing Address - Country:US
Mailing Address - Phone:386-755-2785
Mailing Address - Fax:386-755-1128
Practice Address - Street 1:1615 SW MAIN BLVD
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32025-1108
Practice Address - Country:US
Practice Address - Phone:386-755-2785
Practice Address - Fax:386-755-1128
Is Sole Proprietor?:No
Enumeration Date:2006-07-01
Last Update Date:2011-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0055182207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL061547102Medicaid
FL061547100Medicaid
FL297390OtherAVMED
FL001933700Medicaid
FL4099614OtherAETNA
1180560001OtherMEDICARE/DMERC
180015387OtherRAILROAD MEDICARE
FL297390OtherAVMED
FL001933700Medicaid
FL061547102Medicaid