Provider Demographics
NPI:1790885416
Name:MANN, RANDALL (OD)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:
Last Name:MANN
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 1:127 HENSLEY RD
Mailing Address - Street 2:
Mailing Address - City:SALYERSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41465-9555
Mailing Address - Country:US
Mailing Address - Phone:606-789-4675
Mailing Address - Fax:606-789-3262
Practice Address - Street 1:341 COURT ST
Practice Address - Street 2:
Practice Address - City:PAINTSVILLE
Practice Address - State:KY
Practice Address - Zip Code:41240-1051
Practice Address - Country:US
Practice Address - Phone:606-789-4675
Practice Address - Fax:606-789-3262
Is Sole Proprietor?:No
Enumeration Date:2006-09-23
Last Update Date:2008-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1218DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY77012185Medicaid
KYU25376Medicare UPIN
KY9365204Medicare ID - Type Unspecified