Provider Demographics
NPI:1760483044
Name:NOBLITT, RANDALL L (OD)
Entity Type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:L
Last Name:NOBLITT
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 1:519 STATE ST
Mailing Address - Street 2:
Mailing Address - City:NEW ALBANY
Mailing Address - State:IN
Mailing Address - Zip Code:47150-3620
Mailing Address - Country:US
Mailing Address - Phone:812-948-0616
Mailing Address - Fax:812-949-3447
Practice Address - Street 1:519 STATE ST
Practice Address - Street 2:
Practice Address - City:NEW ALBANY
Practice Address - State:IN
Practice Address - Zip Code:47150-3620
Practice Address - Country:US
Practice Address - Phone:812-948-0616
Practice Address - Fax:812-949-3447
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2020-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1117DT152W00000X
IN18002249A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY2432265000Medicaid
KY1048868Medicaid
KY77340214Medicaid
IN100075970Medicaid
KY000000491358OtherANTHEM
IN100075970Medicaid
INT54126Medicare UPIN
KY00132005Medicare ID - Type Unspecified
KYP00360319Medicare ID - Type UnspecifiedRAILROAD MEDICARE KENTUCK
KY77340214Medicaid