Provider Demographics
NPI:1023087830
Name:ARMSTRONG, RANDALL G (OD)
Entity type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:G
Last Name:ARMSTRONG
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:PO BOX 383
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:IN
Mailing Address - Zip Code:47960-0383
Mailing Address - Country:US
Mailing Address - Phone:574-583-5531
Mailing Address - Fax:574-583-4285
Practice Address - Street 1:1173 W BROADWAY ST
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:IN
Practice Address - Zip Code:47960-1818
Practice Address - Country:US
Practice Address - Phone:574-583-5531
Practice Address - Fax:574-583-4285
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-15
Last Update Date:2008-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18001814152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100088970BMedicaid
IN410037071OtherRR MEDICARE ID#
IN000000090677OtherANTHEM ID#
IN100088970BMedicaid
IN000000090677OtherANTHEM ID#
IN1048420001Medicare NSC