Provider Demographics
NPI:1780622357
Name:RAY, RANDELL R (OD)
Entity type:Individual
Prefix:
First Name:RANDELL
Middle Name:R
Last Name:RAY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
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Mailing Address - Street 1:8924 SOUTHTHORN DR
Mailing Address - Street 2:
Mailing Address - City:N RICHLAND HILLS
Mailing Address - State:TX
Mailing Address - Zip Code:76182-7539
Mailing Address - Country:US
Mailing Address - Phone:817-526-5558
Mailing Address - Fax:817-526-5825
Practice Address - Street 1:1616 W HENDERSON ST
Practice Address - Street 2:
Practice Address - City:CLEBURNE
Practice Address - State:TX
Practice Address - Zip Code:76033-4123
Practice Address - Country:US
Practice Address - Phone:817-526-5558
Practice Address - Fax:817-526-5825
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2017-03-22
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
TX2873TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX281337003Medicaid
TX8F23186OtherMEDICARE PTAN
TX281337001Medicaid
TX0014FGOtherBLUE CROSS BLUE SHIELD OF TEXAS
TX0A5413OtherMEDICARE PTAN