Provider Demographics
NPI:1518945104
Name:WEISHAUS, RANDALL M (OD)
Entity Type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:M
Last Name:WEISHAUS
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 1:220 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MI
Mailing Address - Zip Code:48307-2029
Mailing Address - Country:US
Mailing Address - Phone:248-651-7986
Mailing Address - Fax:248-651-3452
Practice Address - Street 1:220 S MAIN ST
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MI
Practice Address - Zip Code:48307-2029
Practice Address - Country:US
Practice Address - Phone:248-651-7986
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-04
Last Update Date:2016-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004032152W00000X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4148410Medicaid
0F37720OtherMEDICARE PTAN
MI4685330Medicaid
MI1518945104Medicaid
MI4148400Medicaid
MIRW004032OtherBLUE CROSS
MIU78531Medicare UPIN
MI1518945104Medicaid