Healthcare Provider Details

I. General information

NPI: 1659447332
Provider Name (Legal Business Name): RICHARD TRAVIS DOTTERER JR. OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/27/2006
Last Update Date: 02/12/2020
Certification Date: 02/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 GRAND VALLEY BLVD
MARTINSVILLE IN
46151
US

IV. Provider business mailing address

4210 W ESTATE CT
BLOOMINGTON IN
47404-9521
US

V. Phone/Fax

Practice location:
  • Phone: 812-320-0636
  • Fax:
Mailing address:
  • Phone: 812-320-0636
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number18001698B
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: