Provider Demographics
NPI:1417981358
Name:JENTZEN, RANDAL D (OD)
Entity Type:Individual
Prefix:DR
First Name:RANDAL
Middle Name:D
Last Name:JENTZEN
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 1:5221 S COULTER ST
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79119-6676
Mailing Address - Country:US
Mailing Address - Phone:806-358-3594
Mailing Address - Fax:806-457-1660
Practice Address - Street 1:5221 S COULTER ST
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79119-6676
Practice Address - Country:US
Practice Address - Phone:806-358-3594
Practice Address - Fax:806-457-1660
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2018-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX5171TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX092986101Medicaid
TX00010EMedicare PIN
TX092986101Medicaid
TXU57063Medicare UPIN