Provider Demographics
NPI:1396721692
Name:WATKINS, RANDALL B (OD)
Entity type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:B
Last Name:WATKINS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:2109 FOREST AVE
Mailing Address - Street 2:SUITE 50
Mailing Address - City:CHICO
Mailing Address - State:CA
Mailing Address - Zip Code:95928-7680
Mailing Address - Country:US
Mailing Address - Phone:530-342-9644
Mailing Address - Fax:530-342-7547
Practice Address - Street 1:2109 FOREST AVE
Practice Address - Street 2:SUITE 50
Practice Address - City:CHICO
Practice Address - State:CA
Practice Address - Zip Code:95928-7680
Practice Address - Country:US
Practice Address - Phone:530-342-9644
Practice Address - Fax:530-342-7547
Is Sole Proprietor?:No
Enumeration Date:2005-12-19
Last Update Date:2011-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT 5613T TPL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA2413OtherDAVIS VISION
CA8069OtherSAFEGUARD
CASD0056130Medicaid
CA03558OtherMEDICAL EYE SERVICES
CACV07521OtherSPECTERA
CA942220584OtherEMPLOYER ID NUMBER
CA03558OtherMEDICAL EYE SERVICES