Provider Demographics
NPI:1083823611
Name:RICKETTS, RANDALL R (OD)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:R
Last Name:RICKETTS
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 1:1133 W PRATT BLVD
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60626-4403
Mailing Address - Country:US
Mailing Address - Phone:773-510-2769
Mailing Address - Fax:
Practice Address - Street 1:1953 N CLYBOURN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-4945
Practice Address - Country:US
Practice Address - Phone:773-857-1260
Practice Address - Fax:773-857-1624
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2015-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL047.932299152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist