Provider Demographics
NPI:1336247816
Name:RANDLE, ERIC DALE (O D)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:DALE
Last Name:RANDLE
Suffix:
Gender:M
Credentials:O D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2708 WEST OXFORD LOOP
Mailing Address - Street 2:SUITE 110
Mailing Address - City:OXFORD
Mailing Address - State:MS
Mailing Address - Zip Code:38655
Mailing Address - Country:US
Mailing Address - Phone:662-380-5041
Mailing Address - Fax:662-380-5042
Practice Address - Street 1:2708 WEST OXFORD LOOP
Practice Address - Street 2:SUITE 110
Practice Address - City:OXFORD
Practice Address - State:MS
Practice Address - Zip Code:38655
Practice Address - Country:US
Practice Address - Phone:662-380-5041
Practice Address - Fax:662-380-5042
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2023-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS687P-Y152W00000X
MS687152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0880214Medicaid
MS406165OtherMEDICARE
MS004600368Medicaid