Provider Demographics
NPI:1619901550
Name:CORNWALL, RANDY FRANKLIN (OD)
Entity Type:Individual
Prefix:DR
First Name:RANDY
Middle Name:FRANKLIN
Last Name:CORNWALL
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:PO BOX AG
Mailing Address - Street 2:
Mailing Address - City:SPIRIT LAKE
Mailing Address - State:IA
Mailing Address - Zip Code:51360-0328
Mailing Address - Country:US
Mailing Address - Phone:712-336-1960
Mailing Address - Fax:
Practice Address - Street 1:2312 23RD STREET
Practice Address - Street 2:
Practice Address - City:SPIRIT LAKE
Practice Address - State:IA
Practice Address - Zip Code:51360-1044
Practice Address - Country:US
Practice Address - Phone:712-336-1960
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2007-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA02082152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA40832OtherWELLMARK BCBS OF IOWA
IA1162032Medicaid
IA0343680002Medicare NSC
IAU62058Medicare UPIN
IA40832OtherWELLMARK BCBS OF IOWA