Provider Demographics
NPI:1598745689
Name:BUMSTED, RANDALL (OD)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:
Last Name:BUMSTED
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 1:736 BALTIMORE PIKE
Mailing Address - Street 2:CONCORD COMMONS, SUITE 8
Mailing Address - City:GLEN MILLS
Mailing Address - State:PA
Mailing Address - Zip Code:19342-1040
Mailing Address - Country:US
Mailing Address - Phone:610-459-0404
Mailing Address - Fax:610-459-0405
Practice Address - Street 1:736 BALTIMORE PIKE
Practice Address - Street 2:CONCORD COMMONS, SUITE 8
Practice Address - City:GLEN MILLS
Practice Address - State:PA
Practice Address - Zip Code:19342
Practice Address - Country:US
Practice Address - Phone:610-459-0404
Practice Address - Fax:610-459-0405
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-17
Last Update Date:2018-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG-000915152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAP00335886OtherRAILROAD
PA696289Medicare PIN
PA1017740001Medicare NSC
PAP00335886OtherRAILROAD