Provider Demographics
NPI:1396770475
Name:ALLEN, WILLIAM RANDOLPH (OD)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:RANDOLPH
Last Name:ALLEN
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 1:4597 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:TN
Mailing Address - Zip Code:37347-3540
Mailing Address - Country:US
Mailing Address - Phone:423-942-4400
Mailing Address - Fax:423-942-4409
Practice Address - Street 1:4597 MAIN ST
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:TN
Practice Address - Zip Code:37347-3540
Practice Address - Country:US
Practice Address - Phone:423-942-4400
Practice Address - Fax:423-942-4409
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2008-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNODT001454152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3598696Medicaid
TN0158100OtherBLUE CROSS
TN3598696Medicare ID - Type Unspecified
TN0518100001Medicare NSC
TN3598696Medicaid