Provider Demographics
NPI:1023131927
Name:J. RANDALL PITMAN & ASSOCIATES, P.C.
Entity type:Organization
Organization Name:J. RANDALL PITMAN & ASSOCIATES, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:RANDALL
Authorized Official - Last Name:PITMAN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:208-672-1200
Mailing Address - Street 1:8577 W POOL CT
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83714-1797
Mailing Address - Country:US
Mailing Address - Phone:208-853-1953
Mailing Address - Fax:
Practice Address - Street 1:2051 S COLE RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83709-2815
Practice Address - Country:US
Practice Address - Phone:208-672-1200
Practice Address - Fax:208-321-8728
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-08
Last Update Date:2008-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP-715152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1591472Medicare ID - Type UnspecifiedPROVIDER NUMBER
IDT44353Medicare UPIN