Provider Demographics
NPI:1912990193
Name:LANDERS, RICHARD A (OD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:A
Last Name:LANDERS
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 1:3003 FLINTRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-7949
Mailing Address - Country:US
Mailing Address - Phone:678-468-6484
Mailing Address - Fax:
Practice Address - Street 1:6201 SOUTH FREEWAY
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76134-2099
Practice Address - Country:US
Practice Address - Phone:678-468-6484
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-24
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX9402152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
2547OtherOD
TN3946415Medicaid
TN3946415Medicaid
TN3946415Medicare ID - Type Unspecified
ML0823749OtherDEA