Provider Demographics
NPI:1982681706
Name:RANDOLPH, RICHARD NICHOLS (OD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:NICHOLS
Last Name:RANDOLPH
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 1:2240 NASH ST N
Mailing Address - Street 2:
Mailing Address - City:WILSON
Mailing Address - State:NC
Mailing Address - Zip Code:27896-1729
Mailing Address - Country:US
Mailing Address - Phone:252-237-4179
Mailing Address - Fax:252-237-4170
Practice Address - Street 1:2240 NASH ST N
Practice Address - Street 2:
Practice Address - City:WILSON
Practice Address - State:NC
Practice Address - Zip Code:27896-1729
Practice Address - Country:US
Practice Address - Phone:252-237-4179
Practice Address - Fax:252-237-4170
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-22
Last Update Date:2015-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1308152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC09753OtherBLUE CROSS BLUE SHIELD
NC7909753Medicaid
NC09753OtherBLUE CROSS BLUE SHIELD
NCT65071Medicare UPIN
NC7909753Medicaid
NC0768000001Medicare NSC