MEDICARE: RICHARD R PEARSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	01339	WI

General Provider Information

NPI Number	:	1871583765
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RICHARD R PEARSON

Provider Business Mailing Address
First Line	:	PO BOX 130
Second Line	:
City	:	MUKWONAGO
State	:	WI
Zip	:	53149-0130
Country	:	US
Telephone Number	:	262-363-7763
Fax Number	:	262-363-9763

Provider Business Practice Location Address
First Line	:	305 EAGLE LAKE AVE
Second Line	:
City	:	MUKWONAGO
State	:	WI
Zip	:	53149-1163
Country	:	US
Telephone Number	:	262-363-7763
Fax Number	:	262-363-9763

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/24/2005
Last Update Date	:	06/18/2008

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