Provider Demographics
NPI:1144380478
Name:HIMES, RANDALL CROCKETT (OD)
Entity Type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:CROCKETT
Last Name:HIMES
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 1:146 ACADEMY ST
Mailing Address - Street 2:SUITE D
Mailing Address - City:PRESQUE ISLE
Mailing Address - State:ME
Mailing Address - Zip Code:04769-3102
Mailing Address - Country:US
Mailing Address - Phone:207-764-7900
Mailing Address - Fax:
Practice Address - Street 1:146 ACADEMY ST
Practice Address - Street 2:SUITE D
Practice Address - City:PRESQUE ISLE
Practice Address - State:ME
Practice Address - Zip Code:04769-3102
Practice Address - Country:US
Practice Address - Phone:207-764-7900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-08
Last Update Date:2014-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6256310-9934152W00000X
MEOPT948152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist