Provider Demographics
NPI:1932103652
Name:COSHATT, RANDY STEPHEN (OD)
Entity Type:Individual
Prefix:
First Name:RANDY
Middle Name:STEPHEN
Last Name:COSHATT
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 1:112 5TH ST NE
Mailing Address - Street 2:
Mailing Address - City:ALICEVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35442-2200
Mailing Address - Country:US
Mailing Address - Phone:205-373-6374
Mailing Address - Fax:205-373-6163
Practice Address - Street 1:112 5TH ST NE
Practice Address - Street 2:
Practice Address - City:ALICEVILLE
Practice Address - State:AL
Practice Address - Zip Code:35442-2200
Practice Address - Country:US
Practice Address - Phone:205-373-6374
Practice Address - Fax:205-373-6163
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-09
Last Update Date:2009-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS-375-TA-023152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
0275270001OtherCIGNA GOVERNMENT SERVICES
AL51059452OtherBLUE CROSS BLUE SHIELD
AL000059452Medicaid
0275270001OtherDMEPOS
AL000059452Medicaid