Provider Demographics
NPI:1619928587
Name:NORRIS, RANDY H (OD)
Entity Type:Individual
Prefix:DR
First Name:RANDY
Middle Name:H
Last Name:NORRIS
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 1:1257 SW 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:OR
Mailing Address - Zip Code:97914-4516
Mailing Address - Country:US
Mailing Address - Phone:541-889-2191
Mailing Address - Fax:541-881-1523
Practice Address - Street 1:1257 SW 4TH AVE
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:OR
Practice Address - Zip Code:97914-4516
Practice Address - Country:US
Practice Address - Phone:541-889-2191
Practice Address - Fax:541-881-1523
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2017-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP-100098152W00000X
OR3386ATI152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807822301Medicaid
ID807822301Medicaid
ORR165249Medicare PIN
MNT92380Medicare UPIN
MN410001778Medicare ID - Type UnspecifiedMEDICARE