Provider Demographics
NPI:1326663865
Name:WOLFE, RANDY DAVID (OD)
Entity Type:Individual
Prefix:DR
First Name:RANDY
Middle Name:DAVID
Last Name:WOLFE
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 1:515 W BUCKEYE RD STE 104
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85003-3699
Mailing Address - Country:US
Mailing Address - Phone:602-207-8196
Mailing Address - Fax:
Practice Address - Street 1:515 W BUCKEYE RD STE 104
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85003-3699
Practice Address - Country:US
Practice Address - Phone:602-207-8196
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-10
Last Update Date:2020-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOPT-002453152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist