Provider Demographics
NPI:1871583765
Name:PEARSON, RICHARD R
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:R
Last Name:PEARSON
Suffix:
Gender:M
Credentials:
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 130
Mailing Address - Street 2:
Mailing Address - City:MUKWONAGO
Mailing Address - State:WI
Mailing Address - Zip Code:53149-0130
Mailing Address - Country:US
Mailing Address - Phone:262-363-7763
Mailing Address - Fax:262-363-9763
Practice Address - Street 1:305 EAGLE LAKE AVE
Practice Address - Street 2:
Practice Address - City:MUKWONAGO
Practice Address - State:WI
Practice Address - Zip Code:53149-1163
Practice Address - Country:US
Practice Address - Phone:262-363-7763
Practice Address - Fax:262-363-9763
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-24
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI01339152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI87708Medicare PIN
WIT62973Medicare UPIN
WI0150380001Medicare NSC