Provider Demographics
NPI:1629153853
Name:MELCHERT, RANDALL GEORGE (OD)
Entity Type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:GEORGE
Last Name:MELCHERT
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:W137N7657 NORTH HILLS DR
Mailing Address - Street 2:
Mailing Address - City:MENOMONEE FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:53051
Mailing Address - Country:US
Mailing Address - Phone:262-255-6787
Mailing Address - Fax:
Practice Address - Street 1:12750 W CAPITAL DR
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005
Practice Address - Country:US
Practice Address - Phone:262-781-2020
Practice Address - Fax:262-781-6535
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2007-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1634152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
T62748Medicare UPIN
WI000087615Medicare ID - Type Unspecified