Provider Demographics
NPI:1164410387
Name:HOERTH, RANDALL WALTER (OD)
Entity Type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:WALTER
Last Name:HOERTH
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 860
Mailing Address - Street 2:
Mailing Address - City:ALBERTVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35950-1624
Mailing Address - Country:US
Mailing Address - Phone:256-878-3024
Mailing Address - Fax:256-878-3049
Practice Address - Street 1:200 S HAMBRICK ST
Practice Address - Street 2:
Practice Address - City:ALBERTVILLE
Practice Address - State:AL
Practice Address - Zip Code:35950-1624
Practice Address - Country:US
Practice Address - Phone:256-878-3024
Practice Address - Fax:256-878-3049
Is Sole Proprietor?:No
Enumeration Date:2005-10-11
Last Update Date:2008-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS370 TA048152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
4942860001Medicare NSC
ALT68938Medicare UPIN