Provider Demographics
NPI:1568798841
Name:RANDOLPH, ANTWAN PERCY (OD)
Entity Type:Individual
Prefix:DR
First Name:ANTWAN
Middle Name:PERCY
Last Name:RANDOLPH
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:149 TIMBERLINE RD
Mailing Address - Street 2:
Mailing Address - City:SPEARFISH
Mailing Address - State:SD
Mailing Address - Zip Code:57783-9642
Mailing Address - Country:US
Mailing Address - Phone:605-642-2533
Mailing Address - Fax:605-642-2559
Practice Address - Street 1:2549 YUKON PL
Practice Address - Street 2:
Practice Address - City:SPEARFISH
Practice Address - State:SD
Practice Address - Zip Code:57783-8531
Practice Address - Country:US
Practice Address - Phone:605-549-1212
Practice Address - Fax:605-549-1313
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-21
Last Update Date:2021-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010002259152W00000X
TN2911152W00000X
SD748152WV0400X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy