Provider Demographics
NPI:1326031527
Name:PUCKETT, RANDALL K
Entity Type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:K
Last Name:PUCKETT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 HOSPITAL DR STE 160
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:KY
Mailing Address - Zip Code:40391
Mailing Address - Country:US
Mailing Address - Phone:859-744-4429
Mailing Address - Fax:859-745-7702
Practice Address - Street 1:225 HOSPITAL DR BLDG B STE 160
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:KY
Practice Address - Zip Code:40391
Practice Address - Country:US
Practice Address - Phone:859-744-4429
Practice Address - Fax:859-745-7702
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-24
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1190DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY77011906Medicaid
KYMP0229129OtherDEA LICENSE
KYU05928Medicare UPIN
KY0371803Medicare ID - Type Unspecified