Provider Demographics
NPI:1831130566
Name:COREY, RANDALL K (OD)
Entity Type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:K
Last Name:COREY
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 1:1517 SW MARLOW AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97225-5101
Mailing Address - Country:US
Mailing Address - Phone:503-292-5221
Mailing Address - Fax:503-297-3937
Practice Address - Street 1:1517 SW MARLOW AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-5101
Practice Address - Country:US
Practice Address - Phone:503-292-5221
Practice Address - Fax:503-297-3937
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2007-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1035T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
R135833Medicare PIN
T67529Medicare UPIN