Healthcare Provider Details

I. General information

NPI: 1942358320
Provider Name (Legal Business Name): RICHARD VANDYKE PACKARD O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/08/2007
Last Update Date: 08/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

74927 US HIGHWAY 111
INDIAN WELLS CA
92210
US

IV. Provider business mailing address

74927 US HIGHWAY 111
INDIAN WELLS CA
92210-7136
US

V. Phone/Fax

Practice location:
  • Phone: 760-568-2340
  • Fax: 866-529-1713
Mailing address:
  • Phone: 760-568-2340
  • Fax: 866-529-1713

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number9332TPA
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number9332
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: