Provider Demographics
NPI:1467502518
Name:EDWARDS, RANDALL LEE (OD)
Entity Type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:LEE
Last Name:EDWARDS
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 1:1120 RIDGELAND LOOP
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57702-6128
Mailing Address - Country:US
Mailing Address - Phone:605-399-9692
Mailing Address - Fax:605-348-6694
Practice Address - Street 1:501 KANSAS CITY ST
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-3673
Practice Address - Country:US
Practice Address - Phone:605-348-2323
Practice Address - Fax:605-348-6694
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD466152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD9202713Medicaid