Provider Demographics
NPI:1801022504
Name:WIEBELHAUS, RANDY ANTHONY (OD)
Entity Type:Individual
Prefix:DR
First Name:RANDY
Middle Name:ANTHONY
Last Name:WIEBELHAUS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1309 LYNHURST LN
Mailing Address - Street 2:
Mailing Address - City:DENTON
Mailing Address - State:TX
Mailing Address - Zip Code:76205-8079
Mailing Address - Country:US
Mailing Address - Phone:940-484-8857
Mailing Address - Fax:940-387-1998
Practice Address - Street 1:2430 S I-35 E # SOUTH
Practice Address - Street 2:SUITE 156
Practice Address - City:DENTON
Practice Address - State:TX
Practice Address - Zip Code:76205-4986
Practice Address - Country:US
Practice Address - Phone:940-484-8857
Practice Address - Fax:940-387-1998
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-09
Last Update Date:2009-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX4002T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXU12454Medicare UPIN