Provider Demographics
NPI:1962489351
Name:HERTNEKY, RANDY L (OD)
Entity Type:Individual
Prefix:DR
First Name:RANDY
Middle Name:L
Last Name:HERTNEKY
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 1:415 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WRAY
Mailing Address - State:CO
Mailing Address - Zip Code:80758-1724
Mailing Address - Country:US
Mailing Address - Phone:970-332-4823
Mailing Address - Fax:970-848-5346
Practice Address - Street 1:415 MAIN ST
Practice Address - Street 2:
Practice Address - City:WRAY
Practice Address - State:CO
Practice Address - Zip Code:80758-1724
Practice Address - Country:US
Practice Address - Phone:970-332-4823
Practice Address - Fax:970-848-5346
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-27
Last Update Date:2021-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1092152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO08010928Medicaid
CO0233130001Medicare NSC
T60832Medicare UPIN
CO08010928Medicaid