Provider Demographics
NPI:1154463099
Name:ALLDREDGE, BROOKS RANDALL (OD)
Entity Type:Individual
Prefix:DR
First Name:BROOKS
Middle Name:RANDALL
Last Name:ALLDREDGE
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:PO BOX 1506
Mailing Address - Street 2:
Mailing Address - City:CHEHALIS
Mailing Address - State:WA
Mailing Address - Zip Code:98532-0409
Mailing Address - Country:US
Mailing Address - Phone:360-242-3008
Mailing Address - Fax:360-807-7687
Practice Address - Street 1:8220 SAN PEDRO DR NE
Practice Address - Street 2:SUITE 220
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87113-2476
Practice Address - Country:US
Practice Address - Phone:505-797-4466
Practice Address - Fax:505-797-2275
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2020-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP-100001152W00000X
ORATI2539152W00000X
WAOD00001864152W00000X
MTOPT-OPT-LIC-2803152W00000X
NMOPT589152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID8082271700Medicaid
NM01879341Medicaid
WA8884432Medicare PIN
WA8884424Medicare PIN
ID8082271700Medicaid
WA8884431Medicare PIN
NM01879341Medicaid
ID1594500Medicare PIN
WA8884430Medicare PIN
WA8884433Medicare PIN