Provider Demographics
NPI:1174614689
Name:REBUCK, RICHARD CARL (OD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:CARL
Last Name:REBUCK
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 1:805 N MILDRED ST
Mailing Address - Street 2:STE 3
Mailing Address - City:RANSON
Mailing Address - State:WV
Mailing Address - Zip Code:25438-1533
Mailing Address - Country:US
Mailing Address - Phone:304-725-2020
Mailing Address - Fax:304-725-2027
Practice Address - Street 1:805 N MILDRED ST
Practice Address - Street 2:STE 3
Practice Address - City:RANSON
Practice Address - State:WV
Practice Address - Zip Code:25438-1533
Practice Address - Country:US
Practice Address - Phone:304-725-2020
Practice Address - Fax:304-725-2027
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2011-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV0D971152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV9200015000Medicaid
WVVA0404OtherEYE MED
WV00172178OtherMSBCBS
WVU73885Medicare UPIN