Provider Demographics
NPI:1164506739
Name:RANDECKER, MELISSA NANCY (OD)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:NANCY
Last Name:RANDECKER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:930 BELLEFONTE AVE
Mailing Address - Street 2:
Mailing Address - City:LOCK HAVEN
Mailing Address - State:PA
Mailing Address - Zip Code:17745-2754
Mailing Address - Country:US
Mailing Address - Phone:570-748-8900
Mailing Address - Fax:570-748-3200
Practice Address - Street 1:930 BELLEFONTE AVE
Practice Address - Street 2:
Practice Address - City:LOCK HAVEN
Practice Address - State:PA
Practice Address - Zip Code:17745-2754
Practice Address - Country:US
Practice Address - Phone:570-748-8900
Practice Address - Fax:570-748-3200
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2022-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOET08717152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1022033460001Medicaid
PA128145Medicare PIN
PA1022033460001Medicaid